Certification of Health Care Provider
Employee’s Serious Health Condition
(Family and Medical Leave Act)
( )
Section I - For Completion by Employee: Complete the Employee Information section, sign page 3, and give it
to your health care provider to complete. Have your provider return the completed form to you. You will need to
return this form to The Hartford no later than 15 days from the date you requested your leave.
Forms can be mailed to:
OR faxed to:
This form must be returned no later than:
Employee Information
Employee’s Name:
Last 4 digits of Social Security Number:
Leave ID: Date of Birth:
Employer
’s Name:
T oday’s Date:
Employee’s Job Title: Regular Work Schedule:
Employee’s Essential Job Functions:
Check if Job Description Is Attached.
Section II - For Completion by the Health Care Provider: (See Part A and Part B attached)
INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA. Answer
fully and completely, all applicable parts. 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 FMLA 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.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by
GINA Title II from requesting or requiring genetic information of an individual or family member of the individual,
except as specifically allowed by this law. To comply with this law, we are asking that you not provide any
genetic information when responding to this request for medical information. “Genetic information” as defined
by GINA, includes the manifestation of disease or disorder in family members of the individual, an individual’s
family medical history, the results of an individual’s or
family member’s genetic tests, the fact that an individual
or an individual’s family member sought or received genetic services and genetic information of a fetus carried
by an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive
reproductive services.
Provider’s name:
Provider’s Business Address:
Type of Practice/Medical Specialty:
Telephone Number:
( )
Fax Number:
LC-7446-10 MN
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07/2019
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including underwriting companies Hartford Life and Accident Insurance Company
and Hartford Fire Insurance Company. Home Office is Hartford, CT. The Hartford is the administrator for certain group benefits business written by Aetna Life
Insurance Company and Talcott Resolution Life Insurance Company (formerly known as Hartford Life Insurance Company). The Hartford also provides administrative
and claim services for employer leave of absence programs and self-funded disability benefit plans.
