Employee and Retiree Service Center
MONTGOMERY COUNTY PUBLIC SCHOOLS
Rockville, Maryland 20855
Employee Employee No. 0000 Date / /
Last First MI
CERTIFICATION OF PHYSICIAN OR
HEALTH CARE PROVIDER
MCPS Form 440-35, Rev. 9/04
PART II: FOR CERTIFICATION RELATING TO THE EMPLOYEE’S OWN SERIOUS HEALTH CONDITION—To be completed
by the physician or health care provider to verify services.
Estimated dates of absence: From
/ / Thru / /
(Beginning and end dates must be specified and must coincide with days of leave of absence. If an end date can not be specified,
please state this and enter date of next appointment.)
Regimen of Treatment to be Prescribed: (Indicate number of visits, general nature and duration of treatment, including referral to
other provider of health services. Include schedule of visits or treatment if it is medically necessary for the employee to be off work
on an intermittent basis or to work less than the employee's normal schedule of hours per day or days per week.)
INFORMATION RELATING TO THE EMPLOYEE’S OWN SERIOUS HEALTH CONDITIONS.
Date condition commenced:
/ /
State diagnosis and regimen of treatment to be prescribed:
Yes No
1.
Is inpatient hospitalization of the employee required?
2.
Is the employee able to perform work of any kind? (If “No,” Skip item 3.)
3.
Is the employee able to perform the functions of the employee’s position? (Answer after reviewing statement from
employer of essential functions of employee’s position, or, if none provided, after discussing with employee.)
If absence is related to pregnancy, give estimated delivery date:
/ /
PART III: FOR CERTIFICATION RELATING TO CARE FOR THE EMPLOYEE’S SERIOUSLY ILL FAMILY MEMBER—To be
completed by physician or health care provider to verify services.
Employee’s family member:
Relationship to employee:
Last First
Employee’s estimated dates of absence: From / / Thru / /
Yes No
4.
Is inpatient hospitalization of the family member (patient) required?
5.
Does (or will) the patient require assistance for basic medical, hygiene, or nutritional needs, or for safety or transportation?
6.
Is the employee's presence necessary or would it be beneficial for the care of the patient? (This may include psychological
comfort.) If "Yes":
Describe care needed:
Estimate the period of time care is needed or the employee’s presence would be beneficial including a schedule if leave is to
be taken intermittently or on a reduced-leave schedule.
PART IV: AUTHORIZATION—To be completed by physician or health care provider to verify services.
Print Name of Physician or Health Care Provider Phone Number
/ /
Signature, Physician or Health Care Provider Date Type of Practice/Field of Specialization
If question is required concerning this case:
Print Name of Contact Person Phone Number
PART I: PATIENT INFORMATION—To be completed by employee.
