Form Hr Ben 070 – Fill Out and Use This PDF

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

If son or daughter, date of birth:

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

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.

Type of Practice/ Medical Specialty:

Provider’s Address:

Telephone:Fax:

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.