Fillable Form 1: CERTIFICATION OF HEALTH CARE PROVIDER (FAMILY (Mississippi Delta Community College)

Fill Online, Printable, Fillable, Blank Form 1: CERTIFICATION OF HEALTH CARE PROVIDER (FAMILY (Mississippi Delta Community College) Form

Use Fill to complete blank online MISSISSIPPI DELTA COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 1: CERTIFICATION OF HEALTH CARE PROVIDER (FAMILY (Mississippi Delta Community College)

On average this form takes 10 minutes to complete

The Form 1: CERTIFICATION OF HEALTH CARE PROVIDER (FAMILY (Mississippi Delta Community College) form is 3 pages long and contains:

  • 2 signatures
  • 0 check-boxes
  • 30 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Mississippi Delta Community College

BROWSE MISSISSIPPI DELTA COMMUNITY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
JO.99368377.1
CERTIFICATION OF HEALTH CARE PROVIDER
(FAMILY AND MEDICAL LEAVE ACT OF 1993)
1, Employee’s Name:
2. Patient’s Name (if different from employee):
3. The attached sheet describes what is meant by a “serious health condition” under the
Family and Medical Leave Act. Does the patient’s condition
1
qualify under any of the categories
described? If so, please check the applicable category.
(1) (2) (3) (4) (5) (6) , or None of the above
4. Describe the medical facts which support your certification, including a brief statement as
to how the medical facts meet the criteria of one of these categories:
5.a.
State the approximate date the condition commenced, and the probable duration of the
condition (and also the probable duration of the patient’s present incapacity
2
if different):
5.b.
Will it be necessary for the employee to take work only intermittently or to work on a less
than full schedule as a result of the condition (including for treatment described in Item 6
below)?
If yes, give the probable duration:
5.c.
If the condition is a chronic condition (condition #4) or pregnancy, state whether the
patient is presently incapacitated
2
and the likely duration and frequency of episodes of
incapacity
2
:
6.a.
If additional treatments will be required for the condition, provide an estimate of the
probable number of such treatments:
1
Here and elsewhere on this form, the information sought relates only to the condition
for which the employee is taking FMLA leave.
2
“Incapacity,” for purposes of FMLA, is defined to mean inability to work, attend school
or perform other regular daily activities due to the serious health condition, treatment therefor, or
recovery therefrom.
- 2 -
JO.99368377.1
If the patient will be absent from work or other daily activities because of treatment on an
intermittent or part-time basis, also provide an estimate of the probable number and interval
between such treatments, actual or estimated dates of treatment if known, and period required for
recovery if any:
6.b.
If any of these treatments will be provided by another provider of health services (e.g.,
physical therapist), please state the nature of the treatments:
6.c.
If a regimen of continuing treatment by the patient is required under your supervision,
provide a general description of such regimen (e.g., prescription drugs, physical therapy
requiring special equipment):
7.a.
If medical leave is required for the employee’s absence from work because of the
employee’s own condition (including absences due to pregnancy or a chronic condition), is the
employee unable to perform work of any kind?
7.b.
If able to perform some work, is the employee unable to perform any one or more of the
essential functions of the employee’s job (the employee or the employer should supply you with
information about the essential job functions)? If yes, please list the essential
functions the employee is unable to perform:
7.c.
If neither a. nor b. applies, is it necessary for the employee to be absent from work for
treatment?
8.a.
If leave is required to care for a family member of the employee with a serious health
condition, does the patient require assistance for basic medical or personal needs or safety, or for
transportation?
8.b.
If no, would the employee’s presence to provide psychological comfort be beneficial to
the patient or assist in the patient’s recovery?
8.c.
If the patient will need care only intermittently or on a part-time basis, please indicate the
probable duration of this need:
(Signature of Health Care Provider) (Type of Practice)
(Address) (Telephone number)
click to sign
signature
click to edit
- 3 -
JO.99368377.1
To be completed by the employee requesting FMLA leave.
State the care you will provide and an estimate of the period during which care will be provided,
including a schedule if leave is to be taken intermittently or if it will be necessary for you to
work less than a full schedule:
(Employee signature) (date)
Mississippi Delta Community College does not discriminate on the basis of age, race, color, national origin, religion, sex, sexual
orientation, gender identity or expression, physical or mental disability, pregnancy, or veteran status in its educational programs
and activities or in its employment practices. The following person has been designated to handle inquiries regarding the nondiscrimination policies: Steven J. Jones, Vice
President of Administrative Services, Tanner Hall, Suite 202, P. O. Box 668,
Moorhead, MS 38761, 662-246-6304; EEOC@msdelta.edu
click to sign
signature
click to edit
- 4 -
JO.99368377.1
A “Serious Health Condition” means an illness, injury, impairment, or physical or mental
condition that involves one of the following:
1. Inpatient Care
Inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical care facility,
including any period of incapacity
2
or subsequent treatment in connection with or consequent to
such inpatient care.
2. Absence Plus Treatment
(a)
A period of incapacity
2
of more than three consecutive calendar days (including
any subsequent treatment or period of incapacity
2
relating to the same condition), that also
involves:
(1)
Treatment
3
two or more times by a health care provider, by a nurse or
physician’s assistant under direct supervision of a health care provider, or by a provider of health
care services (e.g., physical therapist) under orders of, or on referral by, a health care provider; or
(2)
Treatment by a health care provider on at least one occasion which results
in a regimen of continuing treatment
4
under the supervision of the health care provider.
3. Pregnancy
Any period of incapacity due to pregnancy, or for prenatal care.
4. Chronic Conditions Requiring Treatments
A chronic condition which:
(1)
Requires periodic visits for treatment by a health care provider, or by a nurse or
physician’s assistant under direct supervision of a health care provider;
(2)
Continues over an extended period of time (including recurring episodes of a
single underlying condition); and
3
Treatment includes examinations to determine if a serious health condition exists and
evaluations of the condition. Treatment does not include routine physical examinations, eye
examinations, or dental examinations.
4
A regimen of continuing treatment includes, for example, a course of prescription
medication (e.g., an antibiotic) or therapy requiring special equipment to resolve or alleviate the
health condition. A regimen of treatment does not include the taking of over-the-counter
medications such as aspirin, antihistamines, or salves; or bed-rest, drinking fluids, exercise, and
other similar activities that can be initiated without a visit to a heath care provider.
- 5 -
JO.99368377.1
(3)
May cause episodic rather than a continuing period of incapacity
2
(e.g., asthma,
diabetes, epilepsy, etc.).
5. Permanent/Long-term Conditions Requiring Supervision
A period of incapacity
2
which is permanent or long-term due to a condition for which treatment
may not be effective. The employee or family member must be under the continuing supervision
of, but need not be receiving active treatment by, a health care provider. Examples include
Alzheimer’s, a severe stroke, or the terminal stages of a disease.
6. Multiple Treatments (Non-Chronic Conditions)
Any period of absence to receive multiple treatments (including any period of recovery
therefrom) by a health care provider or by a provider of health care services under orders of, or
on referral by, a health care provider, either for restorative surgery after an accident or other
injury, or for a condition that would likely result in a period of incapacity
2
of more than three
consecutive calendar days in the absence of medical intervention or treatment, such as cancer
(chemotherapy, radiation, etc.), severe arthritis (physical therapy), kidney disease (dialysis).
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 1: CERTIFICATION OF HEALTH CARE PROVIDER (FAMILY (Mississippi Delta Community College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 3 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document