Certification of Health Care Provider for Employee’s Serious Health Condition
(For use when requesting a Medical Leave of Absence)
Please return completed form to Human Resources; SKH 102; 256.824.6908 (fax).
Employee’s Name: _________________________________________________________________
Employee’s Job Title: _______________________________________________________________
Essential Job Functions: _____________________________________________________________
_________________________________________________________________________________
Note to Health Care Provider: Your patient has exhausted all available FMLA hours and has requested a medical leave
of absence. Answer all applicable parts fully and completely. 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 Medical Leave of Absence coverage. Limit your responses to the condition for which the employee is
seeking leave. Do not provide information about genetic tests, genetic services or the manifestation of disease or disorder in
the employee’s family members. Please be sure to sign the form on the last page.
Provider’s name: __________________________________________________________________
Provider’s business address: _________________________________________________________
Type of practice/medical specialty: ____________________________________________________
Telephone: ___________________________________ Fax: _______________________________
Part A: Medical Facts
1. Approximate date condition commenced: _______________________________________
Probable duration of condition: ________________________________________________
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care
facility? ____No ____Yes. If so, dates of admission:
___________________________________________________________________________
2. Was the patient 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:
_____________________________________________________________________________
_____________________________________________________________________________
