REQUEST FOR LEAVE OF ABSENCE (Appendix B)
(To be completed by Employee)
Company Location:
100 – Whittier
110 – PHP Physician Group
Last Name:
First Name:
Department:
Cost Center:
Employee ID:
Home Address:
Date of Hire:
200 – Downey
Phone number:
Personal Email:
Preferred communication method:
Last Day Worked:
Job Title:
If married, does your spouse work for PIH?
If yes, spouse name__________________________
Requesting Time Off: Start
Mail
Email
Is this requested related to an active Worker’s
Compensation claim with PIH?
Yes
No
Date: __________ End Date: __________ Total # of days: _______
Type of Leave you are applying for: (Select those applicable)
MEDICAL
FMLA/CFRA Medical Leave for Self (excluding pregnancy): For an employee’s own serious health
condition
FMLA/PDL Medical Leave for Self – Pregnancy Related Disability: Disability due to pregnancy, childbirth or
related medical condition.
Leave as a Reasonable Accommodation for Self: Leave not covered by FMLA, CFRA, or PDL, or when the
employee is not eligible for or has exhausted leave under FMLA, CFRA, or PDL and is requesting leave as a
reasonable accommodation for a disability.
FAMILY CARE LEAVE (FMLA/CFRA)
Bonding and/or caring for a newborn child or for placement with the employee of a child for adoption or
foster care and to care for the newly placed child
The child was or is expected to be born or placed with me on: ________________
Serious health condition affecting your:
Spouse
Child
Sibling
Parent
Parent-In-Law
Domestic Partner
Grandchild
Grandparent
MILITARY
Explain purpose of leave: _____________________________________________
PERSONAL (*Requires Manager Approval Below) If your leave request qualifies as a personal leave, you understand
that: Based on the business needs, PIH Health reserves the right to fill my position while I am out on personal leave, although it will
attempt to reinstate me at the conclusion of my personal leave to the same or equivalent position, and understand there is no guarantee
of reinstatement following a personal leave.
Manager Name: __________________________Signature: _____________________Date: __________
Appendix B
V.2 Revised 5/4/2017
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Once the Company has obtained all the necessary documents to process your request for leave, Human Resources will
send you a Designation Notice with pertinent information. If you have any questions, please do not hesitate to contact:
PIH Health
LOA Department
Phone: (562)698-0811 x12940
Letty Hernandez LOA Specialist
Email:Leticia.Hernandez@PIHHealth.org
I understand that this leave has NOT been approved until
I receive the approved Designation Notice from Human Resources.
Employee Signature: _________________________________ Date: _________________
I am required to notify my manager of my request for a leave of absence. I understand that I am not obligated to
disclose any information regarding the details of my leave to my manager. My manager’s signature below constitutes
their acknowledgement of this request only. (For Personal leave, refer to Personal Leave section)
Manager Name: __________________________Signature: _____________________Date: __________
Appendix B
V.2 Revised 5/4/2017
2
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
By signing this form, you authorize the release of the following described medical
information by any physician, health care provider, hospital or medical facility to PIH
Health Hospital, Human Resources Department (the “Hospital”) and its authorized
agents and representatives.
This authorization is limited to information regarding any physical or mental limitation(s)
you may have which may affect your ability to perform work at the Hospital.
Specifically, you authorize any physician, health care provider, hospital or medical
facility to consult with the Hospital and release any medical information concerning the
extent to which your medical condition(s) constitute a disability, your ability to perform
work, and your eligibility for consideration for further extensions of your medical leave of
absence, as well as other possible reasonable accommodations.
The Hospital will use this information to determine the extent to which your medical
condition(s) constitute a disability, your ability to perform work, whether further
extensions of your current medical leave are reasonable, and whether any other
accommodations are required.
This authorization shall be effective as of the date of your signature and shall continue in
full force and effect for one year thereafter. You have a right to receive a true copy of
this authorization from the Human Resources Department.
Dated:________________
Employee Name:____________________________
Print Name
By:________________________________________
Employee Signature
Appendix B
V.2 Revised 5/4/2017
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