Certification of Health Care Provider
for Employee’s Serious Health Condition
(Family and Medical Leave Act/California Family Rights Disability Leave)
Employee: Complete the Employee Information section, sign page 2, 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 leave.
Forms can be mailed to: The Hartford
P.O. Box 14869
KY 40512-4869
OR faxed to Toll Free Fax Number: 833-357-5153
Section I: For Completion by the EMPLOYEE
Employee’s Full Name: Last 4 digits of Social Security Number:
Leave ID: Date of Birth:
Employer Name:
Today’s Date:
Employee’s Job Title:
Regular Work Schedule:
Employee’s Essential Job Functions:
Section II: For Completion by the Health Care Provider:
INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA and/or CFRA, as applicable.
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. Please answer the quest
ions below with the specific information requested; terms such as “lifetime,” “unknown,” or
“indeterminate” may not be sufficient to determine FMLA and/or CFRA coverage. Limit your responses to the condition for which the
employee is seeking leave. Please do not provide any medical information unless doing so is specifically authorized by the employee.
Please be sure to sign the form on the last page.
The California Genetic Information Nondiscrimination Act of 2011 (CalGINA) prohibits employers and other covered entities from
requesting, or requiring, genetic information of an individual or family member of the individual except as specifically allowed by law. To
comply with the Act, we are asking that you not provide any genetic information when responding to this request for medical
information. “Genetic Information,” as defined by CalGINA, includes information about the individual’s or the individual's family
member's genetic tests, information regarding the manifestation of a disease or disorder in a family member of the individual, and
includes information from genetic services or participation in clinical research that includes genetic services by an individual or any
family member of the individual. “Genetic Information” does not include information about an individual’s sex or age.
Provider’s Name:
Provider’s Business Address:
Type of Practice / Medical Specialty:
Telephone Number: ( )
Fax Number: ( )
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.
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LC-7515-3 06/2019
Clear Form
Below is a description of what constitutes a “serious health condition” under both FMLA and the CFRA. Does the patient's conditio
qualify as a ser
th c
Yes No
Mark below as applicable:
1. Approximate date medical condition or need for treatment commenced:
2. Probable duration of medical condition or need for treatment:
3. Use the information provided by the employer in Section I to answer this question. If the employer fails to provide a list of the
employee’s essential functions or a job description, answer these questions based upon the employee’s own description of
their job functions.
Is the employee able to perform work of any kind?
If “Yes” is the employee unable to perform one or more of the essential functions of the employee’s position
Yes No
om ____
______ through ___________
Yes No
1. Please certify the type of leave needed (check all appropriate category boxes):
ontinuous Leave
Start date (Estimate): End date (Estimate):
Intermittent Leave: Is it medically necessary for the employee to be off work on an intermittent basis due to the serious
health condition of the employee?
Yes No
If yes, please indicate the estimated frequency of the employee’s need for intermittent leave due to their serious health
condition, and the duration of such leaves (e.g. 1 episode every 3 months lasting 1-2 days):
____________ times per ___________ week(s) ___________ month(s) ______________
Duration: _______________ hours or ___________ day(s) per episode ________________
Reduced Schedule Leave: Is it medically necessary for the employee to work less than the employee’s normal work
schedule due to the serious health condition of the employee
Yes No
If yes, please indicate the part-time or reduced work schedule the employee needs due to their serious
th condition:
___ hour(s) per day; ___days per week, fr
Frequency: _
Time Off for Medical Appointment or Treatment: Is it medically nece
ssary for the employee to take time off work for
doctor’s visits or medical treatment, either by the health care practitioner or another provider of health services?
Yes No
If yes, please indicate the estimated frequency of the employee’s need for leave for doctor’s visits or medical treatment,
and the time required for each appointment, including any recovery period:
Frequency: _____________ times per ___________ week(s) ___________ month(s) ______________
Duration: _______________ hours or ___________ day(s) per episode ________________
Signature of Health Care Provider Date
Signature of Employee Date
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LC-7515-3 06/2019
Employee’s Full Name:
Leave ID:
(1) Serious health condition
An illness, injury (including, but not limited to, on-the-job injuries), impairment, or physical or mental condition of the
employee or a child, parent, or spouse of the employee that involves either inpatient care or continuing treatment,
including, but not limited to, treatment for substance abuse. A serious health condition may involve one or more of the
(2) Hospital Care
Inpatient care in a hospital, hospice, or residential medical care facility, including any period of incapacity or subsequent
treatment in connection with or consequent to such inpatient care. A person is considered an “inpatient” when a heath
care facility formally admits the patient to the facility with the expectation that the patient will remain at least overnight
and occupy a bed, even if it later develops that such person can be discharged or transferred to another facility and
does not actually remain overnight.
(3) Absence Plus Treatment
(A) A period of incapacity of more than three (3) consecutive calendar days (including any subsequent treatment or
period of incapacity
relating to the same condition), that also involves:
(1) Treatment
two (2) or more times by a health care provider, by a nurse or physician’s assistant under direct
supervision of a health care provider, or by a provider of health care services (e.g., physical therapist) under
orders of, or on referral by, a health care provider; or,
(2) Treatment by a health care provider on at least one (1) occasion which results in a regimen of continuing
under the supervision of a health care provider.
(4) Chronic Conditions Requiring Treatment
A chronic condition which:
(A) Requires periodic visits for treatment by a health care provider, or by a nurse or physician’s assistant under direct
supervision of a health care provider;
(B) Continues over an extended period of time (including recurring episodes of a single underlying condition); and
(C) May cause episodic, rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.).
(5) Perman
ent/Long-term Conditions Requiring Supervision
A period of incapacity which is permanent or long-term
due to a condition for which treatment may not be effective. The
employee or family member must be under the continuing supervision of, but need not be receiving active treatment by, a
health care provider. Examples include Alzheimer’s, a severe stroke, or the terminal stages of disease.
(6) Multiple Treatments (Non-Chronic Conditions)
Any period of absence to receive multiple treatments (including any period of recovery therefrom) by a health care
ider or by a provider of health care services under orders of, or on referral by, a health care provider either for
restorative surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity of
more than three consecutive calendar days in the absence of medical intervention or treatment, such as cancer
(chemotherapy, radiation, etc.), severe arthritis (physical therapy) kidney disease (dialysis).
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 condition. 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.
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Employee’s Full Name:
Leave ID: