Fillable Certification For Family Member Non-FMLA - Certification for Family Member Non-FMLA

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Certification For Family Member Non-FMLA - Certification for Family Member Non-FMLA

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1
CERTIFICATION OF HEALTH CARE PROVIDER FOR
FAMILY MEMBER’S SERIOUS HEALTH CONDITION
Wichita State University *Office of Human Resources* Wichita, Kansas 67260-0015
Phone- (316) 978-3065* Fax- (316) 978-3201
(Rev. 04/06/2015)
SECTION I: INSTRUCTIONS to the EMPLOYEE: Please complete this section before giving this form to the medical provider.
Employee’s Full Name: myWSU ID #
Name of family member for whom you will provide care:
Relationship of family member to you:
If family member is your son or daughter, date of birth:
Describe care you will provide to your family member and estimate leave required to provide care:
Employee’s Signature Date
SECTION II: INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested medical leave to care for
your patient. Answer fully and completely, all applicable parts below . Several questions seek a response as to the frequency or duration of a condition,
treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Be as
specific as you can; terms such as “lifetime,” “unknown,” or “indeterminate” may not be sufficient to determine leave coverage. Limit your responses to the
condition for which the employee is seeking leave. Please be sure to sign the form on the last page.
Provider’s Name:
Provider’s Address:
Type of practice / Medical specialty:
Telephone: (________) ____________________________ Fax: (________) _____________________________
MEDICAL FACTS
Approximate date condition commenced:
Probable duration of condition:
Mark below as applicable:
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
No Yes If yes, dates of admission:
Date(s) you treated the patient for condition:
Will the patient need to have treatment visits at least twice per year due to the condition? No Yes
Was medication, other than over-the-counter medication, prescribed? No Yes
Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)?
No Yes If yes, state the nature of such treatments and expected duration of treatment:
Is the medical condition pregnancy? No Yes If yes, expected delivery date:
Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such medical
facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):
AMOUNT OF CARE NEEDED
Will the patient be incapacitated for a single continuous period of time due to his/her medical condition, including any
2
time for treatment and recovery? No Yes
If yes, estimate the beginning and ending dates for the period of incapacity: to
During this time, will the patient need care? No Yes
Explain the care needed by the patient, and why such care is medically necessary:
Will the patient require care on an intermittent or reduced schedule basis,
including any time for recovery? No Yes
Estimate the hours the patient needs care on an intermittent basis, if any:
hour(s) per day; day(s) per week from through
Explain the care needed by the patient, and why such care is medically necessary:
Will the condition cause episodic flare-ups periodically preventing the patient from participating
in normal daily activities? No Yes
Based upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of flare-ups
and the duration of related incapacity that the patient may have over the next six months (e.g. 1 episode every 3 months
lasting 1-2 days):
Frequency: times per week(s) month(s)
Duration: hours or day(s) per episode.
Does the patient need care during these flare-ups? No Yes
Explain the care needed by the patient, and why such care is medically necessary:
Additional Information – Identify Question with Your Additional Answer:
____________________________________________ ____________________________
Signature of Health Care Provider Date
* “Incapacity,” for purposes of medical leave, is defined to mean inability to work, attend school or perform other regular activities due to the serious health condition, treatment therefore, or recovery therefrom.
*Treatment includes examinations to determine if a serious health condition exists and evaluations of the condition. Treatment does not include routine physical examinations, eye examinations, or dental
examinations.
* A regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic), or therapy requiring special equipment to resolve or alleviate the health conditions. A regimen
of treatment does not include the taking of over-the-counter medications such as Aspirin, antihistamines, or salves; or bed-rest, drinking fluids, exercise, and other similar activities that can be initiated without a
visit to a health care provider.
Paperwork Reduction Act Notice and Public Burden Statement
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. § 2616; 29 C.F.R. § 825.500.Persons are not required to
respond to this collection of information unless it displays a currently valid OMB control number. The Department of Labor estimates that it will take an average of 20 minutes for
respondents to complete this collection of information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection information, including
suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Washington,
DC 20210. DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT OR TO WICHITA STATE UNIVERSITY HUMAN
RESOURCES.
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Certification For Family Member Non-FMLA - Certification for Family Member Non-FMLA

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Completed 11 March 2020

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