DNR SOP –HR608 Attachment #5

Certification of Health Care Provider for Family Member’s Serious Health Condition

(Family and Medical Leave Act)

Employee Name:

Employee ID:

For Completion by the Employee:

The Family and Medical Leave Act (FMLA) permits the Georgia Department of Natural Resources to require that you submit a timely, complete, and sufficient medical certification to support a request for Family and Medical Leave (FML) due to a covered family member’s serious health condition. Your response is required to obtain or retain the benefit of FMLA protections. Failure to provide a complete and sufficient certification may result in a denial of your FML request. You must return this form within 15 calendar days of the date listed in the Rights and Responsibilities section of Attachment 2 (enclosed).

Type of Leave Requested:

I am requesting Family and Medical Leave(check one)

Without pay.

With pay. Since I am requesting FML with pay, I am requesting to use the following type(s) of leave (check all that apply)

Holiday Deferral FLSA Compensatory State Compensatory
Annual Sick Personal

Name of family member for whom you will provide care:

Relationship of family member to you:

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

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

Employee Signature: ______Date: ______

For Completion by the Health Care Provider:

Your patient’s family member has requested leave under 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.

Note: 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. 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 or 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, 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 servicesand the manifestation of disease or disorder in the employee’s family members.

Providers Name: ______Specialty:______

Address: ______Telephone#: ______

City, State, Zip:______Fax: ______

Medical Facts:

Approximate date condition commenced: ______

Probable duration of condition: ______

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

Was the patient admitted for an overnight stay in the hospital, hospice, or residential medical care facility?

YesNo If so, dates of admission: ______

Was medication other than over-the-counter medication prescribed?

YesNo

Will the patient need to have treatment visits at least twice per year due to the condition?

YesNo

Was the patient referred to other Health Care Provider(s) for evaluation or treatment (e.g. physical therapist)?

YesNo If so, state the nature of such treatments and expected duration of treatment.

______

Is the medical condition pregnancy?YesNo

If so, expected delivery date: ______

Amount of Care Needed:

Will the patient be incapacitated for a single continuous period of time due to his/her medical condition, including any time for treatment and recovery? Yes No

If so, estimate the beginning and ending dates for the period of incapacity: ______

During this time, will the patient need care? Yes No If so, explain the care needed and why such care is medically necessary: ______

______

______

Will the patient need follow-up treatment appointments due to his/her medical condition? Yes No

If so, estimate the treatment schedule, including any scheduled follow-up appointments. ______

______

Explain the care and why it is medically necessary: ______

______

Will the patient require care on an intermittent basis, including any time for recovery? Yes No

If so, estimate the hours of care the patient will need intermittently: ______

Explain the care needed and why such care is medically necessary: ______

______

______

Is the condition episodic in nature, periodically preventing the patient from performing his/her normal daily activities?

Yes No If so, estimate the frequency and duration of these periods of incapacity.

______

______

Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment): ______

______

______

Signature of Provider:______Date: ______

(No Stamps)

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