Cigna Intermittent FMLA Form - Fill Out and Download PDF Free

The Cigna Intermittent FMLA form serves as a crucial document for employees seeking leave due to their own serious health condition, including pregnancy, childbirth, or related medical conditions, under the Family and Medical Leave Act (FMLA). It requires precise completion by both the employee and their healthcare provider to ensure compliance with regulations and to facilitate the approval process. By seamlessly bridging the gap between employees, healthcare providers, and the FMLA requirements, this form plays a vital role in safeguarding employment rights while addressing health needs.

Ready to secure your FMLA protections? Click the button below to begin the process of filling out your Cigna Intermittent FMLA form.

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Cigna Intermittent FMLA Form - PDF Details

The Cigna Intermittent FMLA form helps employees request intermittent leave under the Family and Medical Leave Act (FMLA) due to a serious health condition, pregnancy, or childbirth. Employees and their healthcare providers must each complete separate sections to certify the medical need and expected leave schedule.

Who Completes the Form

The employee fills in personal information, employer details, and job duties. The healthcare provider completes the medical certification section with the diagnosis, treatment plan, and expected frequency and duration of intermittent leave.

Key Compliance Requirements

The form includes instructions for protecting sensitive genetic information under the Genetic Information Nondiscrimination Act of 2008 (GINA). Both federal FMLA requirements and applicable state-level protections may apply, including California's Pregnancy Disability Leave (PDL) statute and the California Family Rights Act (CFRA).

Submission Deadlines

Employees must return the completed form within the deadline stated in their FMLA designation notice, typically 15 calendar days. Incomplete or late submissions can result in denial of your intermittent leave request.

Question	Answer
Form Name	Cigna Intermittent FMLA Form
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	cigna leave solutions, cigna intermittent fmla form, cigna fmla online, cigna certification leave health

How to Edit Cigna Intermittent Fmla Form Online for Free

Fill out your Cigna FMLA forms online for free without installing any software. Our PDF editor lets you complete, sign, and download your form in minutes. For related documents, see the FMLA Leave Form and the Leave of Absence Request Form.

Steps to Fill Out the Cigna Intermittent FMLA Form Online

Step 1: Click the "Get Form" button at the top of this page to open the PDF editor. All fields will appear in the editor window.

Step 2: Use the editor to add text, edit existing fields, and add a signature. You can insert images or adjust any pre-filled field before saving.

Here is what each section of the form requires:

1. Start with the employee information section. Enter all details in the required fields:

Filling out segment 1 in cigna fmla form

2. Fill in the Date and Employee Job Title fields in the regular work section:

Find out how to complete cigna fmla form part 2

3. Continue with the Employee Job Title and Regular Work fields in this section:

Employee Job Title Regular Work fields in cigna fmla form

4. Section III is for the healthcare provider. Key fields include the diagnosis and treatment dates:

Section III For Completion by the healthcare provider in cigna fmla form

5. Complete the remaining Section III fields to finish the medical certification:

Completing Section III fields in cigna fmla form

Step 3: Review all entries carefully, then click "Done." Create a free FormsPal account to download or email your completed form. Your document is stored securely and we never share your information.

Frequently Asked Questions About the Cigna Intermittent FMLA Form

What is the Cigna Intermittent FMLA form used for?

This form certifies your eligibility for intermittent leave under FMLA due to a serious health condition or pregnancy disability. Your healthcare provider must sign the medical section before you submit it to your employer.

Who fills out the Cigna FMLA form?

The employee completes the personal and employment sections. The healthcare provider completes Section III with the medical certification, including the diagnosis and expected leave schedule.

What related FMLA forms might I need?

Depending on your situation, you may also need the Employee Leave Request Form, the Non-FMLA Medical Certification Form, or the Cigna Appeal Form if your initial request is denied.

Can I fill out and submit this form online?

You can fill it out online using FormsPal's free editor. Print and submit the completed form to your employer's HR department or to Cigna Leave Solutions by the deadline in your designation notice.