Non-FMLA Medical Certification Form PDF Details

In today's complex work environment, balancing health needs and professional responsibilities has become a crucial concern for both employees and employers. The Non-FMLA Medical Certification form serves as a pivotal tool in this balancing act, particularly for circumstances that fall outside the purview of the Family and Medical Leave Act (FMLA). Crafted to support individuals needing a leave of absence due to their own serious health condition or that of a close family member, yet not qualifying for FMLA, this document facilitates a structured process for obtaining the necessary approval. It mandates the provision of a medical certificate from a healthcare provider validating the serious health condition involved. Moreover, it includes detailed sections requiring information about the patient's diagnosis, the commencement and expected duration of the condition, treatment requirements, and the specific impact on the employee's ability to perform their job functions. Employers, through designated human resources or occupational health services, are allowed to use this form to communicate directly with healthcare providers, ensuring that the request for leave is substantiated by adequate medical evidence. In essence, the Non-FFMLA Medical Certification form embodies a necessary protocol that enables employees to address their health needs without compromising their employment security, thereby promoting a healthier, more supportive work environment.

QuestionAnswer
Form Name Non-FMLA Medical Certification Form
Form Length 2 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 30 sec
Other names non fmla intermittent leave, certification non fmla medical, intermittent leave form non fmla leave, non fmla fit for duty form

Form Preview Example

HUMAN RESOURCES

Mercy Medical Center Campus 271฀Carew฀Street฀•฀P.฀O.฀Box฀9012 Springield,฀MA฀01102-9012

413-748-9620

CERTIFICATION OF PHYSICIAN OR PRACTITIONER

(Non-FMLA Medical Leave of Absence)

I agree to provide a medical certificate from a physician verifying the serious health condition of myself, my spouse, child, or parent. I hereby authorize SPHS Occupational Health Services to contact my physician to verify the reason for my requested leave or for any other related information concerning my leave.

Employee Signature _____________________________________________________ Date _______________________

1. Employee’s Name: ______________________________ SPHS Facility: _____________________________________

2.Patient’s name (If other than employee): ________________________________________________________________

3.Check the applicable category - Serious Health Condition – Diagnosis (Check one)

1)

___ Hospital Care

4)

___ Multiple Treatments (Non-Chronic) conditions including recovery

2)

___ Pregnancy/Prenatal Care

5)

___ Chronic Condition requiring treatments

3)

___ Permanent/Long-term condition

6)

___ Absence plus Treatment (two or more times) by a health care

 

requiring supervision

 

provider at least one occasion with continuing treatment under

 

 

 

supervision of health care provider

4.Describe the medical facts which support your certification (Diagnosis):_______________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

5.a. State the approximate date the condition commenced: ___________________________________________________

b.Will it be necessary for the employee to take work intermittently? If yes, give probable duration: _________________

________________________________________________________________________________________________

c.If condition is chronic or pregnancy state whether patient is presently incapacitated and the likely duration:

________________________________________________________________________________________________

Non-FMLA Medical Leave – Employee’s Own Serious Illness

1.a. If additional treatments will be required for the condition, provide an estimate of the probable number of such treatments: _____________________________________________________________________________________

b.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 probably number of and interval between such treatments, actual or estimated dates of treatment if known, and period required for recovery if any:_________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

c.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: ___________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Form฀#SPHS046HUR฀ •฀ 9/09

11/03

 

d.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): ________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

2.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? explain: ________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

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 of the employee is unable to perform:_________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

c.If neither a nor b applies, is it necessary for the employee to be absent from work for treatment? Explain: _________

______________________________________________________________________________________________

______________________________________________________________________________________________

Non-FMLA Medical Leave – To Care for Seriously ILL Family Member:

1.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? Explain: __________________

______________________________________________________________________________________________

______________________________________________________________________________________________

b.If no, would the employee’s presence to provide psychological comfort be beneficial to the patient or assist in the patient’s recovery? Explain: ________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

c.If the patient will need care only intermittently or on a part-time basis, please indicate the probable duration of

this need: ______________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

2.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: __________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

______________________________________________________________

__________________________________

Signature of Physician or Practitioner

Type of Practice:

______________________________________________________________

__________________________________

Address

Telephone Number

______________________________________________________________

__________________________________

 

Date

11/03

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Stage number 1 of completing non fmla medical leave certification form

2. After filling out the previous section, go to the next part and enter all required particulars in these fields - b Will it be necessary for the, c If condition is chronic or, NonFMLA Medical Leave Employees, a If additional treatments will, treatments, b If the patient will be absent, basis also provide an estimate of, dates of treatment if known and, c If any of these treatments will, and state the nature of the treatments.

basis also provide an estimate of, c If any of these treatments will, and b If the patient will be absent inside non fmla medical leave certification form

Be really careful while filling out basis also provide an estimate of and c If any of these treatments will, because this is where most people make some mistakes.

3. In this step, have a look at FormSPHSHUR. Each one of these are required to be filled out with greatest focus on detail.

non fmla medical leave certification form completion process clarified (step 3)

4. Filling out d If a regimen of continuing, a If medical leave is required, including absences due to, b If able to perform some work is, c If neither a nor b applies is it, and NonFMLA Medical Leave To Care for is essential in the fourth section - you should definitely don't rush and take a close look at each blank area!

non fmla medical leave certification form conclusion process detailed (portion 4)

5. The form has to be wrapped up by dealing with this part. Further there can be found a comprehensive list of blanks that must be filled out with accurate details for your form usage to be accomplished: a If leave is required to care, require assistance for basic, b If no would the employees, patients recovery Explain, c If the patient will need care, this need, State the care you will provide, leave is to be taken, Signature of Physician or, and Type of Practice.

Best ways to fill in non fmla medical leave certification form portion 5

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