SECTION II
FOR COMPLETION BY A UNITED STATES DEPARTMENT OF DEFENCE (DOD) HEALTH CARE PROVIDER OR A HEALTHCARE PROVIDER WHO IS EITHER : 1) A US DEPT.
OF VETERANS AFFAIRS )(VA) HEALTHCARE PROVIDER; 2) A DOD TRICARE NETWORK AUTHORIZED PRIVATE HEALTHCARE PROVIDER; 3) A DOD NON-NETWORK
TRICARE AUTHORIZED PRIVATE HEALTHCARE PROVIDER; 4) A HEALTHCARE PROVIDER AS DEFINED IN THE FMLA.
(If you are unable to make certain of the military-related determinations contained below in Part B, you are permitted to rely upon
determination from an authorized DOD representative (such as a DOD recovery care coordinator).
INSTRUCTIONS TO THE HEALTHCARE PROVIDER:
The employee listed on Page 1has requested leave under the military caregiver leave provision of the FMLA to care for a family member who is a veteran.
For purposes of FMLA military caregiver leave, a serious injury or illness means an injury or illness incurred by the servicemember in the line of duty on active duty
in the Armed Forces (or that existed before the beginning of the member's active duty and was aggravated by service in the line of duty on active duty in the
Armed Forces) and manifested itself before or after the servicemember became a veteran, and is:
(i) a continuation of a serious injury or illness that was incurred or aggravated when the covered veteran was a member of the Armed Forces and rendered the
servicemember unable to perform the duties of the servicemember's office, grade, rank, or rating; or
(ii) a physical or mental condition for which the covered veteran has received the U. S. Department of Veterans Affairs Service Related Disability Rating (VASRD) of
50 percent or greater, and such VASRD rating is based, in whole or in part, on the condition precipitating the need for military caregiver leave; or
(iii) a physical or mental condition that substantially impairs the covered veteran's ability to secure or follow a substantially gainful occupation by reason of a
disability or disabilities related to military service, or would do so absent treatment; or
(iv) an injury, including a psychological injury, on the basis of which the covered veteran has been enrolled in the Department of Veterans Affairs Program of
Comprehensive Assistance for Family Caregivers.
A complete and sufficient certification to support a request for FMLA military caregiver leave due to a covered veteran's serious injury or illness includes written
documentation confirming that the veteran's injury or illness was incurred in the line of duty or existed before the beginning of the veteran's active duty and was
aggravated by service in the line of duty on active duty, and that the veteran is undergoing treatment, recuperation, or therapy for such injury or illness by a
healthcare provider listed above.
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 FLMLA coverage. Limit your responses to the veteran's condition for which the
employee is seeking leave. Do not provide information about genetic tests or genetic services.
PLEASE PRINT CLEARLY OR TYPE. SIGN THE FORM ON THE LAST PAGE (PAGE 3)
A physical or mental condition for which the covered veteran has received the U. S. Department of Veterans Affairs Service Related
Disability Rating (VASRD) of 50 percent or greater, and such VASRD rating is based, in whole or in part, on the condition precipitating the
need for military caregiver leave; or a physical or mental condition that substantially impairs the covered veteran's ability to secure or
follow a substantially gainful occupation by reason of a disability or disabilities related to military service, or would do so absent treatment
