Form Hr Ben 070 PDF Details

Navigating through the world of family medical leave can often seem overwhelming, yet the HR BEN 070 form provides a structured pathway for employees needing time off to care for a family member with a serious health condition. This document, essential for the application process under the Family and Medical Leave Act (FMLA), requires detailed information from both the employee and a certified health care provider. Its comprehensive nature ensures that all parties involved - the employee, the employer, and medical professionals - are on the same page regarding the health condition and the subsequent need for leave. From instructing employees on initial steps, including submission of the FMLA Application Form (HR-BEN-028), to detailing the care required for the family member, the form acts as a bridge between personal medical needs and professional obligations. Furthermore, it emphasizes the importance of timely and accurate medical certification, as failure to adhere to these guidelines may lead to the denial of FMLA leave requests. The form also outlines the consequences of non-compliance, underlining the critical role it plays in the FMLA leave approval process. The HR BEN 070 form underscores a thoughtful approach to handling sensitive health-related leave requests, safeguarding both the rights of the employee and the operational needs of the employer.

QuestionAnswer
Form NameForm Hr Ben 070
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other nameshr ben 070 form, NYCTA, BSC, hr ben 070

Form Preview Example

FMLA Certification of Health Care Provider

Family Member’s Serious Health Condition

HR-BEN-070

Section I – Instructions for the Employee

NOTE: Remember to complete and submit an HR-BEN-028: Family and Medical Leave Act Application Form to your Agency HR or FMLA Coordinator.

Please complete Section I before giving this form to your family member or his/her medical provider. The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave to care for a covered family member with a serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections. 29 U.S.C. §§ 2613, 2614(c)(3). Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA request. 29 C.F.R. § 825.313. Your employer must give you at least 15 calendar days to return this form to your employer. 29 C.F.R. § 825.305.

If you have any questions, please contact MTA Business Service Center (BSC) at 646-376-0123 or bscservice@mtabsc.org.

Section II – Employee Information

Print Name Last

 

 

First

 

M

Suffix

BSC ID:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BSC

B&T

 

CC

HQ

Police

MaBSTOA

 

Department:

 

 

Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

(check one)

 

 

 

 

 

 

 

 

 

 

 

 

 

SIR

LIRR

 

MNR

MTA Bus

NYCTA

 

 

 

Job Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Regular Work Schedule

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone (H)

 

 

Phone (W)

 

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

Name of Family Member for whom you will provide care:

Relationship of family member to you:

 

Parent

Spouse

Child

If son or daughter, date of birth:

Describe the care you will provide to your family member and estimate leave needed to provide care:

Employee Signature

Date

Section III – For Completion by 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 3

provides space for additional information, should you need it. Please be sure to sign the form on page 3.

Provider’s Name:

License number:

State:

Type of Practice/ Medical Specialty:

Provider’s Address:

City:

State:

Zip Code:

Telephone:Fax:

Business Service Center HR-BEN-070

Page 1 of 4

Rev. 11.15.12

 

FMLA Certification of Health Care Provider

Family Member’s Serious Health Condition

HR-BEN-070

PART A: MEDICAL FACTS

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:________________________________________________

Was medication, other than over-the-counter medication, prescribed? ___No ___Yes

Will the patient need to have treatment visits at least twice per year due to the condition? ___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:

___________________________________________________________________________________

___________________________________________________________________________________

2.Is the medical condition pregnancy? ___No ___Yes If so, expected delivery date: _________________

3.Describe other relevant medical facts, if any, related to the condition for which the patient needs care (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

PART B: AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that your patient’s

need for care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or transportation needs, or the provision of physical or psychological care:

4.Will the patient be incapacitated for a single continuous period of time, including any time for treatment and recovery? ___No ___Yes

Estimate the beginning and ending dates for the period of incapacity: _____________________________

During this time, will the patient need care? ___ No ___ Yes

Explain the care needed by the patient and why such care is medically necessary:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Business Service Center HR-BEN-070

Page 2 of 4

Rev. 11.15.12

 

FMLA Certification of Health Care Provider

Family Member’s Serious Health Condition

HR-BEN-070

5.Will the patient require follow-up treatments, including any time for recovery? ___No ___Yes

Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period:

___________________________________________________________________________________

Explain the care needed by the patient, and why such care is medically necessary:

___________________________________________________________________________________

6.Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery?

___No ___Yes

Estimate the hours the patient needs care on an intermittent basis, if any:

_______ hour(s) per day; _______ days per week from ________________ through ________________

Explain the care needed by the patient, and why such care is medically necessary:

____________________________________________________________________________________

____________________________________________________________________________________

7.Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily activities? ____No ____Yes

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., 1 episode every 3 months lasting 1-2 days):

Frequency: _____ times per _____ week(s) _____ month(s)

Duration: _____ hours or ____ day(s) per episode

Does the patient need care during these flare-ups? ____ No ____ Yes

Explain the care needed by the patient, and why such care is medically necessary:

____________________________________________________________________________________

____________________________________________________________________________________

ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Section IV – Signature of Health Care Provider

I do hereby certify that to the best of my knowledge the above information is true and correct.

Signature

Business Service Center HR-BEN-070

Rev. 11.15.12

Date

Page 3 of 4

FMLA Certification of Health Care Provider

Family Member’s Serious Health Condition

HR-BEN-070

Section V – Agency Contact

This Certification form must be sent to your specific Agency representative. Below is a list of all of the Agency contacts. Please check the

appropriate box next to your own Agency’s contact.

Please select only

one box next to the Agency Name, Address, and Contact Information appropriate Agency.

MTA & MTA Capital Construction

MTA Medical Department

Occupational Health Services

420 Lexington Avenue, Suite 2201

New York, NY 10017

Attn: Nurse Manager

LIRR

Human Resources Department

93-02 Sutphin Boulevard

Jamaica, NY 11435

Metro-North Railroad

FMLA Administrator

Human Resources

347 Madison Avenue, 4th Floor

New York, NY 10017

Staten Island Railroad (SIR)

Human Resources Department

60 Bay Street

Staten Island, NY 10301

NYCT / MaBSTOA / MTA BUS

Occupational Health Services

180 Livingston Street

Brooklyn, NY 11201

Business Service Center HR-BEN-070

Page 4 of 4

Rev. 11.15.12

 

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