Health Care Provider
Resume:
CERTIFICATION OF HEALTH CARE PROVIDER FOR MEDICAL LEAVE
Family and Medical Leave Act of 1993 (“FMLA”)
Employee’s Statement: To be completed by EMPLOYEE
The FMLA requires that you submit a timely, complete, and sufficient medical certification to support a request for FMLA due to your or your covered family member’s serious health condition. Failure to submit a timely, complete, and sufficient medical certification may result in a delay or denial of your leave request. Employee Name:
Employee ID No. (NOT SSN)
er
Employer Name:
Date of Birth:
Employee’s current work schedule:
Day: M T W Th F Sa Su
Hours
Total average hours worked per week: If irregular schedule, please describe: Please specify the period of time during which you are requiring any sort of leave: From: / / through / / Will you require intermittent leave? Yes No Anticipated Return to Work Date: / / Part A - Reason for Leave (choose one from numbers 1-4): 1. Your own health condition preventing you from performing the essential functions of your job and/or daily living 2. Your Own Pregnancy:
a. Estimated date of delivery: / / Actual delivery date / / 3. Bonding with a new child in your home:
a. Natural Child Date of Birth / /
b. Adopted Child Date of Birth / / Date of Adoption / / c. Foster Child Date of Birth / / Date of Placement / / If requesting a leave for bonding, the Health Care Provider Statement is NOT required. Return the signed form along with proof of birth, adoption or foster placement to 4. To care for family member with a serious health condition: Family Member Name Relationship: Child Parent Spouse Other a. If Other, please describe relationship (additional family members and/or domestic partner may not be covered by FMLA but may qualify under state laws and/or Company Policy) b. If caring for a child, give Date of Birth : / / c. What care will you be providing the family member: Part B - Employee Acknowledgement: By placing my signature below I acknowledge and certify that:
· All information contained herein is true and correct.
· I have not made and will not make alterations to the Health Care Provider’s Statement.
· I understand that it is my responsibility to return this completed Statement with the Health Care Provider‘s Statement
(“Certification”) and any clarifying, missing, or incomplete information later requested within the specified timelines to
· I understand failure to provide a timely, complete, and sufficient Certification may result in a denial of my FMLA request. IMPORTANT NOTICE: 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 employees or their family members. In order to comply with this law, we are asking that you not provide any Genetic Information when responding to this request for medical information, unless, with respect to leave to care for a family member with a serious health condition, failure to provide the information will result in an incomplete or insufficient certification. “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. Employee’s Signature: Date:
Work Location
LeaveID:
Fax:
Wendy Noel Reed Macy's
11450219
Alight
Alight
Alight
75029
P.O. Box 299093
Lewisville TX
Health Care Provider Statement: To be Completed by Health Care Provider Employee Name: Employer Name:
Patient Name (if different from Employee): IMPORTANT NOTICE TO PROVIDER: This employee has requested leave either for his/her own serious health condition or to care for a family member with a serious health condition. A COMPLETED FORM is necessary to determine whether the employee’s requested time off is available and protected by the FMLA and/or applicable state laws. IMPORTANT NOTICE: 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 employees or their family members. In order to comply with this law, we are asking that you not provide any Genetic Information when responding to this request for medical information, unless, with respect to leave to care for a family member with a serious health condition, failure to provide the information will result in an incomplete or insufficient certification. “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. Part A – Medical Facts:
1. The patient’s condition meets the following factor(s) (necessary to determine whether the condition meets the definition of a
“Serious Health Condition” as defined in the FMLA). Complete all that apply: a. Inpatient Care (overnight stay) in hospital, hospice or residential medical care facility: Date of Admission / / Date of Discharge: / /
b. Pregnancy:
i. Are there complications? Yes No
ii. If yes, describe the complications. (Do not answer without patient consent in CA, ME, or RI): Note: Documentation of complications may be required to substantiate incapacity time prior to delivery iii. Estimated Date of Delivery / /
iv. Actual Delivery Date / /
c. Incapacity Plus Treatment:
The patient’s period of incapacity has or will exceed three (3) days AND the patient meets one of the following criteria: i. The patient will require more than two (2) office visits within thirty (30) days of the first day of incapacity; OR
ii. One (1) office visit resulting in a regimen of continuing treatment (e.g., continuing treatment under the supervision of a physician, nurse, or physician’s assistant or by health care provider’s referral to a provider of health care services, such as a physical therapist).
Note: One in-person office visit is required within 7 days of the first date of incapacity d. Chronic Condition: requires at least 2 visits per year for treatment by a health care provider, continues over an extended period of time and may cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.)
e. Permanent Long Term Condition: may not require treatment, but requires the supervision of a health care provider
(such as Alzheimer’s Disease, terminal illness, severe stroke). f. Conditions Requiring Multiple Treatments: period of absence to receive multiple treatments and to recover from treatments either for: a condition that would likely result in a period of incapacity for more than 3 days in the absence of medical intervention or treatment (such as chemotherapy for cancer, dialysis for kidney disease, or physical therapy for severe arthritis); OR restorative surgery after an accident or injury. g. None of the above.
LeaveID:
Fax:
Wendy Noel Reed Macy's
Alight
75029
P.O. Box 299093
Lewisville TX
2. If the employee is requesting leave for his/her own health condition, at the time of any needed absence from work, is he/she unable to perform any of his/her essential job duties due to this condition? Yes No a. If yes, identify the essential job duties the employee is unable to perform: 3. Note: Health Care Provider must complete this section: Provide the medical facts that support the identification of this condition as a “Serious Health Condition” for which the patient needs FMLA leave from work (may include diagnosis, symptoms, treatment or supervision, surgery, hospitalization, etc.) and the treatment or symptoms of this condition that prevent the employee from performing his/her essential job duties.
(Do not provide medical facts without patient consent in CA, ME or RI. Do not provide diagnosis without patient consent in CA, CT, ME, or RI.):
Optional: Please list the ICD code(s) (Do not complete without patient consent in CA, CT, ME, or RI): 4. Note: Health Care Provider must complete this section if the employee is requesting leave to care for a family member. Please describe what care the patient needs from the employee and why such care is medically necessary: 5. a. What is the approximate date the condition commenced? b. When was the first time you treated the patient for this condition? c. When was the most recent date you treated the patient for this condition? d. When is the patient’s next scheduled appointment? e. What is the probable duration of this condition (Please provide your best estimate; “unknown” or “indeterminate” may not be sufficient to determine FMLA coverage)? Part B – Treatment Needed:
1. Is medication prescribed for this condition (other than over-the-counter medication)? Yes No 2. Was the patient referred to other health care provider(s) for evaluation or treatment? Yes No 3. Name and contact information of the health care provider to whom patient was referred: 4. Specialty of health care provider to whom patient was referred (Do not provide specialty without patient consent in CA, CT, ME, or RI): LeaveID:
Fax:
Alight
75029
P.O. Box 299093
Lewisville TX
Part C – Amount of Leave Needed (more than one leave type may be selected): Fill in the corresponding section indicating the type of leave(s) your patient’s serious health condition requires. Enter the START and END dates of the appropriate type(s) of FMLA leave in the sections below. For the frequency or duration of the patient’s condition or treatment, please provide your best estimate based upon your medical knowledge, experience and examination of the patient. Terms such as “unknown” or “indeterminate” may not be sufficient to determine FMLA coverage.
1. CONTINUOUS LEAVE:
Will the employee be incapacitated for a single continuous period of time due to his/her medical condition?
(Yes/No)
If yes, please complete the following:
a. Start date of leave: / / End date of leave: / / 2. REDUCED LEAVE:
Is it is medically necessary for the employee to reduce the number of hours of the employee’s daily or weekly work schedule?
(Yes/No)
If yes, please complete the following:
a. Start date of leave: / / End date of leave: / / b. Reduced Schedule: days per week hours per day and/or week 3. INTERMITTENT LEAVE:
Is it medically necessary for the employee to take leave in intermittent periods of time?
(Yes/No)
If yes, please complete the following:
a. Incapacity (Estimated Episodic Flare-Ups):
i. Start date: / / End date: / /
ii. Episodes will be times every days (use 7, 30, 365). Each episode of incapacity may last up to hours or days. (e.g., 2 times every 30 days, lasting up to 1 day) b. Office Visits and/or Treatment Schedule (Excluding Incapacity Time): i. Start date: / / End date: / /
ii. Office visits and/or treatments will be time(s) every days (use 7, 30, 365). Each office visit and/or treatment will last approximately hours. (e.g., 2 times every 30 days, lasting up to 2 hours) Part D – Health Care Provider Signature:
I certify the above information is accurate and truthful to the best of my knowledge. I certify that I completed this form based on the medical information and facts derived from my treatment or care of the patient. Signature: Date Form Completed and Signed:
Print Name: Title (MD, DO, etc.): Type of Practice: Address:
Phone Number: Fax Number:
LeaveID:
Fax:
MACY-1471-672415927684
Alight
75029
P.O. Box 299093
Lewisville TX
LeavePro
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Welcome to LeavePro
It’s Fast, Easy & Online
You can view and manage your leave from a computer, tablet or mobile device with LeavePro. Save time by going online to quickly address your basic leave needs. Available 24/7, simply log in via the internet:
More Features to Better Manage Your Leave
With LeavePro, you can more efficiently manage your leave online at your convenience. Intuitive, streamlined navigation helps you quickly find leave information or complete leave tasks. It’s all at your fingertips – no need to call to complete these actions. You can:
• Easily submit a new leave, manage a current leave, and view details of all leaves
• Quickly view and complete your required tasks to keep leave request moving forward
• Receive alerts and notifications, via text and/or email, to keep informed of leave status
• Securely upload documents via computer or mobile device; please have all documentation ready to upload at one time
• View leave status and remaining time available
• Add time-off request to an intermittent leave; reporting must be completed as outlined in your employer’s internal leave policy
• View and confirm expected date for returning to work Mobile Home Page Desktop Home Page
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