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

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FMLA HCP Employee 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 EMPLOYEE'S SERIOUS HEALTH CONDITION
OHRM - FMLA- CERTIFICATION OF HEALTHCARE PROVIDER FOR EMPLOYEE SERIOUS HEALTH CONDITION FORM - 2015. Page 1
Contract Title
Empl. ID
Department
Section 1: TO BE COMPLETED BY EMPLOYER
Health Care Provider's Name
Name of Employee
City
State
Zip Code
Job description attached
Regular Work Schedule
Essential Job Functions
(If job description is not attached)
FMLA permits CUNY to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due
to your own serious health condition. If requested by CUNY, your response is required to obtain or retain the benefit of FMLA protections.
Failure to provide a complete and sufficient medical certification may result in denial of your FMLA request.
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. 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 employee is seeking 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
Type of Practice /Medical Speciality:
Telephone
FAX
Address
City
State
Zip Code
Country
Tel.:
FAX
FMLA FORM- 3 A
College
FAMILY AND MEDICAL LEAVE ACT (FMLA)
CERTIFICATION OF HEALTH CARE PROVIDER FOR EMPLOYEE'S SERIOUS HEALTH CONDITION
PART A: MEDICAL FACTS
OHRM - FMLA- CERTIFICATION OF HEALTHCARE PROVIDER FOR EMPLOYEE SERIOUS HEALTH CONDITION FORM - 2015. Page 2
Approximate date condition commenced
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
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
No
Yes
Is the employee unable to perform any of his/her job functions due to the condition?
Use the information provided by the Employer in Section 1 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 his/her job.
If yes, identify the job functions the employee is unable to perform:
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):
Dates you treated the patient for a condition
If yes, state the nature of such treatments and expected duration of treatment:
From
To
OHRM - FMLA- CERTIFICATION OF HEALTHCARE PROVIDER FOR EMPLOYEE SERIOUS HEALTH CONDITION FORM - 2015. Page 3
FAMILY AND MEDICAL LEAVE ACT (FMLA)
CERTIFICATION OF HEALTH CARE PROVIDER FOR EMPLOYEE'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., 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
If yes, explain
Is it medically necessary for the employee to be absent from work during the flare-ups?
Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job functions?
No
No
Yes
Yes
To
From
Days per week
Hour(s) per day
Estimate the part-time or reduced work schedule the employee
needs, if any:
Estimate treatment schedule, if any including the dates of any scheduled appointments and the time required for each appointment,
including any recovery period:
No
Yes
If yes, are the treatments or the reduced number of hours of work medically necessary?
No
Yes
Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced schedule because
of the employee's medical condition?
If yes, estimate the beginning and end dates for the period of incapacity:
PART B: AMOUNT OF LEAVE NEEDED
Will the employee be incapacitated for a single continuous period of time due to his/her medical condition, including any
time for treatment and recovery?
From
To
No
Yes
OHRM - FMLA- CERTIFICATION OF HEALTHCARE PROVIDER FOR EMPLOYEE SERIOUS HEALTH CONDITION FORM - 2015. Page 4
FAMILY AND MEDICAL LEAVE ACT (FMLA)
CERTIFICATION OF HEALTH CARE PROVIDER FOR EMPLOYEE'S SERIOUS HEALTH CONDITION
ADDITIONAL INFORMATION:
IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER:
SIGNATURE OF HEALTH CARE PROVIDER
DATE
PRINT NAME OF HEALTH CARE PROVIDER
LICENSE #
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FMLA HCP Employee Form 3-9-16 (City University of New York)

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Completed 18 December 2020

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