Fill and Sign the Elaws Family and Medical Leave Act Advisor Us Department of Labor Form

FMLA CERTIFICATION OF PHYSICIAN 1. Employee’s name 2. Patient’s name (if other than employee) 3. Diagnosis 4. Date condition commenced 5. Probable duration of condition 6. Regimen of treatment to be prescribed (Indicate number of visits, general nature and duration of treatment, including referral to other provider of health services. Include schedule of visits or treatment if it is medically necessary for the employee to be off work on an intermittent basis or to work less than the employee’s normal schedule of hours per day or days per week): By PhysicianBy another provider of health services, if referred by Physician If this certification relates to care for an employee’s seriously ill family member, skip items 7, 8 and 9 and proceed to items 10 through 14.Check Yes or No in the boxes below, as appropriate: Yes No 7. Is inpatient hospitalization of the employee required?8. Is employee able to perform work of any kind? (If “No” skip Item 9.)9. Is employee able to perform the functions of employee’s position? (Answer after reviewing statement from employer of essential functions of employee’s position, or, if none provided, after discussing with employee.)Signature of Physician: Date: Type of Practice (Field of Specialization, if any): For certification relating to care for the employee’s seriously ill family member, complete items 10 through 14 as they apply to the family member.Check Yes or No in the boxes below, as appropriate. Yes No 10. Is inpatient hospitalization of the family member (patient) required?11. Does (or will) the patient require assistance for basic medical, hygiene, nutritional needs; safety; or transportation?12. After review of the employee’s signed statement (See Item 14 below), is the employee’s presence necessary or would it be beneficial for the care of the patient? (This may include psychological comfort.)13. Estimate the period of time care is needed or the employee’s presence would be beneficial: < Item 14 to be completed by employee needing family leave. 14. When Family Leave is needed to care for a seriously ill family member, the employee shall state the care he or she will provide and an estimate of the time period during which this care will be provided, including a schedule if leave is to be taken intermittently or on a reduced leave schedule: Employee Signature: Date: Manager: Company/Division/Location: CER TIF IC A TIO N O F P H YSIC IA N O R P R ACTIT IO NER Retu rn c o m ple te d f o rm in a s e ale d e nve lo pe, m ark e d p ers o nal a nd c o nfid entia l, t o : E M PLO YEE/P A TIE N T I N FO RM ATIO N AND I N FO RM ED C O NSEN T F O R D IS C LO SU RE O F H EA LTH C ARE I N FO RM ATIO N Em plo ye e's N am e: Socia l S ecu rit y N um ber:E m plo ye e's A ddre ss:C it y , S ta te , Z ip : Tele phone N um ber:P atie nt's N am e:P atie nt's A ge: Rela tio nsh ip t o E m plo ye e:H IP A A-C O M PLIA NT A UTH O RIZ A TIO N T O R ELE A SE I N FO RM ATIO N:By co m ple tin g th is docu m ent, I dem onstr a te m y in fo rm ed co nse nt and auth oriz a tio n to allo w th e ph ysic ia n or pra ctit io ner id entif ie d on th is fo rm to re le ase and dis clo se to ___ ___ _______________________________________ su ch healt h ca re re co rd s and in fo rm atio n con ce rn in g m y c u rre nt m edic a l c o ndit io n a s is n ece ssa ry to s u pport m y re quest fo r a le ave o f a bse nce and /o r a ny a ddit io nal b enefit s th e e m plo ye r m ay p ro vid e. T his a uth oriz a tio n is m ade p er m y re quest. Th is a u th oriz a tio n s h all b e v a lid fo r tw o (2 ) y e ars fr o m th e d ate s h ow n b elo w , u nle ss re vo ke d b y m e in writ in g a t a n e arlie r d ate . A lt h ough I u nders ta nd th at I m ay re vo ke th is a uth oriz a tio n in w rit in g a t a ny tim e, I a ls o u nders ta nd th at a ny s u ch re vo ca tio n w ill n ot a pply to a ny in fo rm atio n th at h as a lr e ady b een re le ase d in re lia nce o n th is a uth oriz a tio n, a nd th at a ny re vo ca tio n m ay h ave a n a dve rs e e ffe ct o n th e re ce ip t o f e m plo ye r-p ro vid ed b enefit s . I u nders ta nd th at m y m edic a l tr e atm ent is n ot c o ndit io ned u pon me p ro vid in g th is a uth oriz a tio n . I u nders ta nd th at if th is a u th oriz a tio n is fo r th e r e le ase o f p sych oth era py no te s I w ill co m ple te a se para te a uth oriz a tio n fo r a ny o th er h ealt h in fo rm atio n. I u nders ta nd th at in fo rm atio n d is clo se d b y th e p hysic ia n o r p ra ctit io ner to th e e m plo ye r m ay b e s u bje ct to r e dis clo su re a nd not p ro te cte d b y t h e H ealt h I n su ra nce P orta bilit y a nd A cco un ta bilit y A ct o f 1 996 ( “H IP AA”).E m plo ye e S ig natu re : _ _____________________________________________ Date :A lt e rn ativ e ly , s ig natu re o f P ers o nal R epre se nta tiv e a nd s ta te m ent o f a uth orit y t o a ct o n b ehalf o f in div id ua l: _ __ ___ ________________________ ______________________________ Date :IF P A TIE N T I S A DULT F A M IL Y M EM BER O F E M PLO YEE:P atie nt S ig natu re : Date : I F P A TIE N T I S M IN O R C HIL D :Sig natu re o f P are nt o r G uard ia n: Date :