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City of Belgrade - FMLA Paperwork 1 Health Care Provider Certification SECTION I: INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because of a need for leave due to a serious health condition to submit a medical certification issued by the employee’s health care provider. Employers must generally maintain records and documents relating to medical certifications, re- certifications, or medical histories of employees 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: Contact: Regular Work Schedule: Contact’s essential job functions: City of Belgrade Human Resources, [PHONE REDACTED] 8:00 – 5:00 PM, Monday through Friday Manage Human Resource Functions within the City SECTION II: INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your medical provider. The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a request for Family Medical Leave (FML) due to your own 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. 29 C.F.R. §825.305(b). Your Full Name: First Middle Last SECTION III: INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA. Answer, fully and completely, all applicable parts. 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 employee is seeking leave. Please be sure to sign the form on the last page. In lieu of this from, a Health Care Provider may provide a written summary of the information requested on health care provider letterhead with an original signature. Please ensure pertinent areas below are addressed in the written summary such as dates, type of illness/pregnancy, duration, etc. Medical Provider’s Name: Medical Provider’s Business Address: Type of practice / Medical specialty: Telephone: ( ) Fax: ( ) ---PAGE BREAK--- City of Belgrade - FMLA Paperwork 2 PART A: MEDICAL FACTS 1. Approximate date condition commenced: Probable duration of condition: Mark below as applicable: Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility? No Yes If yes, dates of admission: Date(s) you treated the patient for condition: Will the patient need to have treatment visits at least twice per year due to the condition? No _Yes Was medication, other than over-the-counter medication, prescribed?_____ No Yes Was the patient referred to other health care provider(s) for evaluation or treatment physical therapist)? Yes If yes, state the nature of such treatments and expected duration of treatment: 2. Is the medical condition pregnancy? No Yes. If yes, expected delivery date: 3. Use the information provided by the employer in Section I to answer this question. If the employer fails to provide a list of the employee’s essential functions or a job description, answer these questions based upon the employee’s own description of his/her job functions. Is the employee unable to perform any of his/her job functions due to the condition: No Yes. If yes, identify the job functions the employee is unable to perform: 4. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such medical facts may include diagnosis, or any regimen of continuing treatment such as the use of specialized equipment: PART B: AMOUNT OF LEAVE NEEDED 5. Will the employee be incapacitated for a single continuous period of time due. to his/her medical condition, including any time for treatment and recovery? No Yes If yes, estimate the beginning and ending dates for the period of incapacity: 6. Will the employee need to attend follow-up treatment appointments or work part-time or on a ---PAGE BREAK--- City of Belgrade - FMLA Paperwork 3 reduced schedule because of the employee’s medical condition? No Yes If yes, are the treatments or the reduced number of hours of work medically necessary? Yes Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period: Estimate the part-time or reduced work schedule the employee needs, if any: hour(s) per day; days per week from through 7. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job functions? No Yes 8. Is it medically necessary for the employee to be absent from work during the flare-ups? No Yes If yes, explain: 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 1 episode every 3 months lasting 1-2 days): Frequency: times per week(s) month(s) Duration: hours or day(s) per episode ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER. Attach additional pages if necessary: Signature of Health Care Provider Date PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. § 2616; 29 C.F.R. § 825.500.Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. The Department of Labor estimates that it will take an average of 20 minutes for respondents to complete this collection of information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC 20210. DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.