Certification of Health Care Provider for Employee’s/Family
Member’s Serious Health Condition
Physcian’s Name
Medical Group Name
Phone Number
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)
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Fax:
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Annette Rabago, RN, CCM, MPA
Assistant Vice President, HR Operations
Work: (210) 458-4031
Fax: (210) 458-4644
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PLEASE PRINT
Last Name
First Name
EMPL ID
Shift
Middle Initial
Date
Supervisor
Phone
/
Phone Number
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)
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(
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)
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I give permission to my physicians or other health care providers, hospitals, or clinics to release the information on this form and, upon
request, to release my medical information relating to this injury/illness to my employer, UTSA. I understand that this information will be used
to assist my employer in evaluating my injury/illness, my work status and eligibility for Family Medical Leave.
Employee’s Signature:
Date:
Job description available upon request
FMLA ELIGIBLE (pending Approval):
It is our understanding that you are treating:
Job description is attached
The above named employee is requesting Family Medical Leave from The University of Texas at San Antonio.
The
Patient is:
Childs age:
The employee is requesting full day leave from:
The employee is requesting leave on an intermittent
or reduced schedule on the follow ing dates:
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/
To
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/
To
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/
To be completed by Physician or an Authorized Health Care Provider
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting
or requiring genetic information of employees or their family members. In order to comply with this law, we are asking that you not
provide any genetic information when responding to this request for medical information. “Genetic information,” as defined by GINA,
includes an individual’s family medical history, the results of an individual’s family medical history, the results of an individual’s or family
member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic
information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member
receiving assistive reproductive services.
Please assist us by clarifying the facts about the requested leave by completing the information below. Here and elsewhere on this form, the
information sought relates only to the condition for which the employee is taking FMLA Leave.
1. As an authorized medical care provider,
I certify that I am currently treating:
Name of Patient
2.
The patient has/is receiving treatment
for the following condition (Diagnosis optional):
Follow-up visit required:
3.
4.
5.
The condition
began on:
Date of follow-up visit:
/
/
Approximate return
to work date:
.
/
/
/
.
/
.
The back of this sheet describes what is meant by a “serious health condition” under the Family and Medical Leave Act as made
applicable by the Congressional Accountability Act. Does the patient’s condition qualify under any of the categories described? If so,
please check the applicable category.
1.
2.
3.
4.
5.
6.
None of
the above
Describe the medical facts which support your certification, including a brief statement as to how the medical facts meet the criteria one of
these categories:
Prescription medications:
Physician or Authorized Health Care Provider Signature
Diagnostic studies:
Date
Type of Practice
Office Mailing Address:
Rev.May 2014
/hr/docs/FMLA/PhysicianCertification.doc
Phone #:
FAMILY MEDICAL LEAVE ACT: What is a “Serious Health Condition”?
A “Serious Health Condition” refers to an illness, injury, impairment, or physical or mental condition that involves
the following:
1.
Hospital Care
Inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical care facility, including any
period of incapacity or subsequent treatment in connection with or consequent to such inpatient care.
Incapacity, for FMLA purposes, is defined as the inability to work, attend school or perform other regular daily
activities due to the serious health condition, treatment therefor, or recovery therefrom.
2.
Absence Plus Treatment
Treatment includes examinations to determine if a serious health condition exists and evaluation of the
condition treatment does not include routine physical examinations, or dental examinations. A period of
incapacity of more than three consecutive calendar days (including any subsequent treatment or period of
incapacity relating to the same condition), that also involves:
a)
Treatment two or more times by a health care provider, by a nurse or physician’s assistant under direct
supervision of a health care provider, or by a provider of health care services (e.g., physical therapist)
under orders of, or on the referral by, a health care provider; or
b)
Treatment by a health care provider on at least one occasion which results in a regimen of continuing
treatment under the supervision of the health care provider. A regimen of continuous treatment
includes, for example, a course of prescription medication (e.g., an antibiotic) or therapy requiring
special equipment to resolve or alleviate the health condition. A regimen of treatment does not include
the taking of over-the-counter medications such as aspirin, antihistamines or salves; or bedrest,
drinking fluids, exercise, and other similar activities that can be initiated without a visit to a health care
provider.
3.
Pregnancy
Any period of incapacity due to pregnancy or for prenatal care.
4.
Chronic conditions requiring Treatments
A chronic condition which:
a)
Requires periodic visits for treatment by a health care provider, or by a nurse or physician’s assistant
under direct supervision of a health care provider.
b)
Continues over an extended period of time (including recurring episodes of a single underlying
condition); and
c)
May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.)
but, does not necessarily require a visit to a physician at the time of occurrence. For example, a patient
with asthma who has not been advised to stay home when pollen count is high or a pregnant woman
with morning sickness.
5.
Permanent/Long-Term Conditions Requiring Supervision
A period of incapacity which is permanent or long term due to a condition for which treatment may not be
effective. The employee or family member must be under the continuing supervision of, but need not be
receiving active treatment by, a health care provider. Examples include Alzheimer’s, a severe stroke or the
terminal stages of a disease.
6.
Multiple Treatments (Non-Chronic Conditions)
Any period of absence to receive treatments (including any period of recovery therefrom) by a health
care provider or by a provider of health care services under orders of, or on referral by, a health care
Rev.May 2014
/hr/docs/FMLA/PhysicianCertification.doc
provider, either for restorative surgery after an accident or other injury, or for a condition that would
likely result in a period of incapacity of more than three consecutive calendar days in the absence of
medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe arthritis
(physical therapy) and kidney disease (dialysis).
Rev.May 2014
/hr/docs/FMLA/PhysicianCertification.doc