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:
’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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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.
PART A - Medical Facts
(For Completion by the Health Care Provider)
Employee’s Name:
Approximate date condition commenced: Probable duration of condition:
) Was the employee admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
If so, dates of admission:
No Yes
) Date(s) you treated the employee in your office for condition:
) Will the employee need to have treatment visits at least twice per year due to the condition?
) Was medication, other than over-the-counter medication, prescribed? No Yes
) Was the employee referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)?
No Yes If so, state the nature of such treatments and expected duration of treatment.
) Is the medical condition pregnancy? No Yes
so, expected delivery date:
) Use the information provided in Section I to answer this que . If a list of the employee's essential functions
or a job description is not included in section I, answer these questions based upon the employee’s own
description of his/her job functions.
Is the employee unable to perform any of his/her job functions due to the condition? No Yes
If so, identify the job functions the employee is unable to perform.
8) Provide the Medical Facts that support your certification. Such medical facts may include symptoms,
diagnosis, or any regimen of continuing treatment as the use of specialized equipment. (NOTE: 1) Do not
include diagnosis information for employees/patients who work in CT, ME, or RI. 2) Do not complete
this section for employees/patients who work in HI or MT if you answered YES to question 6 above ).
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PART B: Amount Of Leave Needed:
(For Completion by the Health Care Provider)
1) Will the employee be incapacitated for a single continuous period of time, including any time for treatment and
recovery? No Y es
If so, estimate the beginning and ending dates for the period of incapacity: through
2) Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced schedule
because of the employees medical condition? No Yes
If so, are the treatments or the reduced number of hours of work medically necessary? No
Estimate treatment/appointment schedule, if any, over the next 6 months including any recovery period:
Treatment/Appointment Frequency: times per
week(s) or month(s)
Employee’s Name
Leave ID:
Duration: hours or days(s) per treatment/appointment
Dates of scheduled treatment(s)/appointment(s):
4) Estimate the part-time or reduced work schedule the employee needs if any:
hour(s) per day; days per week from through
5) Will the condition cause episodic flare-ups periodically preventing the employee from participating in normal
daily activities? No
6) Is it medically necessary for the employee to be absent from work during the flare-up s? No Ye
If so, explain:
7) Based upon the employee’s medical history and your knowledge of the medical condition, estimate the
frequency of flare-ups and the duration of related incapacity that the employee may have over the next 6 months:
(e.g., 1 episode every 3 months lasting 1-2 days)
times per week(s) month(s)
Duration: hours or day(s) per episode
Additional Information not provided above relative to the leave request.
Signature of Health Care Provider Date
Signature of Employee Date
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. 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.
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