701 E Carson Street Carson, CA 90745 Telephone (310) 952-1736 Fax (310) 830-2471
III. REQUESTED TIME OFF WORK:
A. Will the employee be incapacitated for a single continuous period of time, including time for treatment and recovery.
No Yes – provide start and end dates, below:
____________________________ _______________________________ ____________________________________
Leave Start Date Expected Leave End Date Expected Return to work date
B. Will the employee need intermittent time off due to this serious health condition?
No Yes – if Yes, are these absences medically necessary? No Yes, if so provide details below:
Frequency: ____________ hour/days per week/month, or: __________
_______________________ __________________________ Duration: _____________ hours per day, or: ______________
Intermittent Period Intermittent Period Will these absences be consecutive? No Yes
Start Date End Date -If yes, up to ____________days in a row.
*if period end date is not known, please provide an estimated date that re-evaluation will occur.
Estimate the treatment schedule, if any, including the dates of any scheduled appointments and the time required for
each appointment including recovery period:
Dates of Appointments Time Required Per Appointment Recovery Period Required
C. Will the employee need to work part-time or a reduced work schedule due to this serious health condition?
No Yes - if yes, is this schedule medically necessary? No Yes, if so provide details below:
_______________hours per work day, _____________days per workweek
Reduced Schedule Reduced Schedule
Start Date End Date
IV. Limited Authorization for Release of Health Care Information
Employee’s Name Employee’s Date of Birth
I authorize the release of any medical information necessary to complete this form. Knowingly providing false information directly, or
through another party, may result in adverse action against the employee.
Employee’s Signature Date
CERTIFICATION BY PROVIDER: By signing below you are certifying that the information you have provided is
accurate and complete, and that this information is based on your personal knowledge of the patient’s condition.
___________________________________________________ ______________________________ _________________________________
Provider’s Printed Name and Credentials Type of Practice Telephone Number
Provider’s Office Address (Street, City, State, Zip Code) Best times & Days to Call
Provider’s Signature (No stamps or Proxy Seals Accepted) Date