Form Wh 380 F – Fill Out and Use This PDF

Certification of Health Care Provider for Family Member’s Serious Health Condition (Family and Medical Leave Act)

SECTION I: For Completion by the EMPLOYER

INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FLMA protections because of a need for leave to care for a covered family member with a serious health condition to submit a medical certification issued by the health care provider of the covered family member. Please complete Section I before giving this form to your employee. Your response is voluntary. While you are not required to use this form, you may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306- 825.308. Employers must generally maintain records and documents relating to medical certifications, recertifications, or medical histories of employees’ family members, created for FMLA purposes as confidential medical records in separate files/records from the usual personnel files and in accordance with 29 C.F.R. §1630.14(c)(1), if the Americans with Disabilities Act applies.

Employer name and contact: Southern Westchester BOCES, 17 Berkley Drive, Rye Brook, NY 10573,

Human Resources Department, Telephone: (914) 937-3820 or Fax: (914) 937-7644

SECTION II: For Completion by the EMPLOYEE

INSTRUCTIONS to the EMPLOYEE: Please complete Section 11 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.

Your name:

First

Middle

Last

Name of family member for whom you will provide care:

First

Middle

Last

Relationship of family member to you:

If family member is your son or daughter, date of birth:

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

Employee Signature

Date

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Form WH-380-F Revised January 2009

SECTION III: For Completion by the HEALTH CARE PROVIDER

INSTRUCTIONS to 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 4 provides space for additional information, should you need it. Please be sure to sign the form on the last page.

Provider’s name and business address: _______________________________________________________

Type of practice/ Medical specialty: _________________________________________________________

Telephone: (

) _________ ______________ Fax: (

) ____________________________

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?

Date(s) you treated the patient for condition: _______________________________________________

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.

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):

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Form WH-380-F Revised January 2009

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 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: ____________________________

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

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:

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Form WH-380-F Revised January 2009

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) ______months(s)

Duration: _____hours or _____days(s) per episode

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

ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.

Signature of Health Care Provider

Date

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Form WH-380-F Revised January 2009