Fillable FMLA HCP Employee Family Form 3-9-16 (City University of New York)

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FMLA HCP Employee Family Form 3-9-16 (City University of New York)

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FAMILY AND MEDICAL LEAVE ACT (FMLA)
CERTIFICATION OF HEALTH CARE PROVIDER FOR
FAMILY MEMBER'S SERIOUS HEALTH CONDITION
OHRM - FMLA- CERTIFICATION OF HEALTHCARE PROVIDER FOR FAMILY MEMBER'S SERIOUS HEALTH CONDITION FORM - 2015. Page 1
Empl. ID
Department
Section 1: TO BE COMPLETED BY EMPLOYER
Health Care Provider's Name
Tel.
Name of Employee
City
State
Zip Code
FMLA permits CUNY to require that you submit a timely, complete and sufficient medical certification to support a request for FMLA leave to
care for a covered family member with a serious health condition. If requested by CUNY, your response is required to obtain or retain the
benefits of FMLA protections. Failure to provide a complete and sufficient medical certification may result in denial of your FMLA request.
Please complete this section and attach the CERTIFICATE OF FAMILY RELATIONSHIP FORM before giving this form to your family member or
his/her Health Care Provider.
CUNY gives you at least 15 calendar days to return this form.
Section II: INSTRUCTIONS TO EMPLOYEE
This form must be returned by
The employee listed above has requested leave under the FMLA to care for your patient.
- 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 FMLA coverage.
- Limit your responses to the condition for which the patient needs care.
- Do not provide information about genetic tests, genetic services, or the manifestation of disease or disorder in the employee's family
members.
PLEASE PRINT CLEARLY OR TYPE. SIGN THE FORM ON THE LAST PAGE (Page 4)
Section III: INSTRUCTIONS TO HEALTH CARE PROVIDER
Address
City
State
Zip Code
Country
Tel.:
FAX
Type of Practice / Medical Speciality
Name of family member for whom you will provide care
CERTIFICATE OF FAMILY RELATIONSHIP FORM MUST BE ATTACHED
Describe care to be provided by you
Estimate leave needed
FAX
FMLA FORM-3 B
College
FAMILY AND MEDICAL LEAVE ACT (FMLA)
CERTIFICATION OF HEALTH CARE PROVIDER FOR FAMILY MEMBER'S SERIOUS HEALTH CONDITION
PART A: MEDICAL FACTS
OHRM - FMLA- CERTIFICATION OF HEALTHCARE PROVIDER FOR FAMILY MEMBER'S SERIOUS HEALTH CONDITION FORM - 2015. Page 2
Approximate date condition commenced
Probable duration of condition
Yes
Answer as applicable
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
No
If yes, dates of admission
From Date
To Date
Will the patient need to have treatment visits at least twice per year due to the condition?
No
Yes
No
Yes
Was medication, other than over-the-counter medication, prescribed?
No
Yes
Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)?
No
Yes
Is the medical condition pregnancy?
If yes, expected date of delivery
Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such medical facts may include
symptoms, diagnosis, or any regimen of continuing treatment, such as the use of specialized equipment):
PART B: AMOUNT OF CARE NEEDED
When answering these questions, keep in mind that your patient's need for care by the employee seeking leave may include
assistance with basic medical, hygienic, nutritional, safety or transportation needs, or the provision of physical or psychological care.
No
Yes
Will the patient be incapacitated for a single continuous period of time due to his/her medical condition, including any time
for treatment and recovery?
From date
If yes, estimate the beginning and end dates for the period of incapacity:
To date
No
Yes
Will the patient require follow-up treatments, including any time for recovery?
Estimate treatment schedule, if any including the dates of any scheduled appointments and the time required for each appointment, including
any recovery period:
Explain the care needed by the patient and why such care is medically necessary:
Explain the care needed by the patient and why such care is medically necessary
Dates you treated the patient for condition
If yes, state the nature of such treatments and expected duration of treatment:
During this time, will the patient need care?
No
Yes
OHRM - FMLA- CERTIFICATION OF HEALTHCARE PROVIDER FOR FAMILY MEMBER'S SERIOUS HEALTH CONDITION FORM - 2015. Page 3
FAMILY AND MEDICAL LEAVE ACT (FMLA)
CERTIFICATION OF HEALTH CARE PROVIDER FOR FAMILY MEMBER'S SERIOUS HEALTH CONDITION
Based upon the patient's medical history and your knowledge of the medical condition, estimate the frequency of flare-ups and the duration of
related incapacity that the patient may have over the next 6 months (e.g., one episode every 3 months lasting 1-2 days):
Frequency
No. of times per week
No. of times per month
No. of day(s) per episode
No. of hours per episode
Duration
Does the patient need care during these flare-ups?
Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily activities?
Yes
No
No
Yes
Explain the care needed by the patient and why such care is medically necessary
Explain the care needed by the patient and why such care is medically necessary
PART B: AMOUNT OF CARE NEEDED (continued)
To date
From date
Days per week
Hour(s) per day
Estimate the hours the patient needs care on an intermittent basis, if any
No
Yes
Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery?
OHRM - FMLA- CERTIFICATION OF HEALTHCARE PROVIDER FOR FAMILY MEMBER'S SERIOUS HEALTH CONDITION FORM - 2015. Page 4
DATE
LICENSE #
SIGNATURE OF HEALTH CARE PROVIDER
PRINT NAME OF HEALTH CARE PROVIDER
IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER
ADDITIONAL INFORMATION:
FAMILY AND MEDICAL LEAVE ACT (FMLA)
CERTIFICATION OF HEALTH CARE PROVIDER FOR FAMILY MEMBER'S SERIOUS HEALTH CONDITION
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FMLA HCP Employee Family Form 3-9-16 (City University of New York)

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Completed 18 December 2020

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