Alabama A&M University Certification of Physician or Practitioner Form for Family Member’s Serious Health Condition
Office of Human Resources July 2016
2
Section III: For completion by the Health Care Provider.
Instructions to the Health Care Provider: The employee listed above has requested leave under the FMLA to care
for your patient. Answer, fully, and completely, all applicable parts below. 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 leave. Page 4 provides space for additional information, should you need it.
Please be sure to sign the form on the last page.
Provider’s name and business address:
Type of practice/medical specialty:
Telephone: ( ) Fax: ( )
Part A: Medical Facts
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by
GINA Title II from requesting or requiring genetic information of an individual or family member of the individual,
except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic
information when responding to this request for medical information. ‘Genetic Information’ as defined by GINA
includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the
fact that an individual or an individual’s family member sought or received genetic services, and genetic
information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an
individual or family member receiving assistive reproductive services.
1. Approximate date condition commenced:
Probable duration of condition:
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
No Yes. If so, dates of admission:
Date(s) you treated the patient for condition:
Will the patient need to have treatment visits at least twice per year due to the condition?___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. If so, state the nature of such treatments and expected duration of
treatment:
