Checklist

Read Instructions

 Read Family Medical Leave Information

Notified Supv.

Notified ServiceCenter

Supv. Called ServiceCenter with last day worked

Completed the form

Signed and dated the form

Gave form to Doctor

Reviewed for completeness & accuracy then

mailed or faxed form to the ServiceCenter

Received Approval/Denial Letter

McDonald’s Medical Leave of Absence without Pay Instructions/Checklist

Instructions/General Information:

The following are instructions and a checklist, which will guide you through the Medical Leave of Absence without Pay Process. Read through the instructions to familiarize yourself with the entire process. Then go back and as you complete each required action, check the box on the left. Each box represents an action you need to take.

IF YOU NEED ASSISTANCE

Contact McDonald’s ServiceCenter at 1-877-623-1955. For additional information regarding Leave of Absences, see McDonald’s Helping Balance Your Work and Life.

Si usted tiene preguntas sobre este material, favor de llamar al centro de servicio de

McDonald’s 1-877-623-1955.

A request for a Medical Leave of Absence Without Pay (MLWOP) may also qualify as a request for a Family and Medical Leave, depending upon your eligibility. If you qualify for a Family and Medical Leave, your Medical Leave without pay will run concurrently with your family medical leave. In order for your request to be processed appropriately, it is important that you understand your rights and responsibilities. Refer to the enclosed “Family and Medical Leave Rights and Responsibilities” sheet, which contains information regarding your rights under the Family and Medical Leave Act of 1993.

To get your leave started:

  • Notify your supervisor and the ServiceCenter of your need for a leave.
  • When you stop working, you must remind your supervisor to notify the ServiceCenter of your last day worked so that the ServiceCenter can stop your pay to avoid an overpayment. The leave does not begin until your supervisor notifies us of your last day worked. Check with your supervisor to be sure that he/she has notified the ServiceCenter.

Medical Leave of Absence without Pay Application Form

  • To apply for a Medical Leave of Absence Without Pay, you must complete the Medical Leave of Absence Without Pay Application/ExtensionFormincluded in this packet. You may also be eligible for a Family Medical Leave of Absence, please contact the ServiceCenter.
  • Complete the Employee Information section at the top of the form.
  • After reading the Patient Authorization section, sign and date the form.
  • Give the signed form to your physician and have the physician complete the Attending Physician Information. The physician should retain a copy for their records and return the completed form to you. (This must be a medical doctor, we do not accept midwives; assistants; nurse practitioners; etc.)
  • Mail or Fax the completed form to the McDonald’s ServiceCenter. The address and fax number can be found at the bottom of your application. Retain a copy of the form for your records.
  • Once your MLWOP application is thoroughly completed we will forward your application to our medical consultants. They will review the form, contact your physician’s office, and recommend approval or denial of your application. If the leave is approved, they will determine the appropriate length of the leave. McDonald’s reserves the right of final approval on all medical claims. Generally, the approval process will take seven to ten business days to review your application, provided your physician responds in a timely manner.
  • When the ServiceCenter receives the approval or denial from our medical consultants, you will be notified with a letter.
  • To continue Medical/Dental/Life Insurance and Healthcare FSA you must have been covered by the benefit immediately prior to the Leave Of Absence. You will receive a letter with information about the costs and procedures for continuing your insurance.

Filled out Extension Form

Signed & Dated Form

Gave form to my Doctor

Reviewed for completeness & accuracy then mailed or faxed form to the ServiceCenter

Received Approval/Denial Letter

Completed Form

Signed & Dated form

Reviewed for completeness & accuracy

Gave form to Doctor

Gave form to Supervisor

 Mailed or faxed form to the ServiceCenterSupv. called ServiceCenter with return to work date

Next Steps:

  • If you need to continue your leave, complete another MLWOP Application/Extension Form following the instructions below to apply for extension of benefits.
  • You may be eligible for Long Term Disability benefits if you are disabled for more than 180 consecutive days. Please contact the ServiceCenter for additional information.
  • If you are not eligible for Long Term Disability you will need to continue to apply for a Medical Leave of Absence Without Pay. As long as you are approved, you may be on a Short Term Disability or Medical Leave of Absence Without Pay for up to 30 months.
  • If you do not need to continue your leave, please go to the Return to Work section.

MEDICAL LEAVE WITHOUT PAY APPLICATION/EXTENSION FORM: (Extension)

  • If you are out on an approved MLWOP and are unable to return to work by the expected date, you must complete a Medical Leave of Absence Without Pay Application/ Extension Form. An additional copy of the Medical Leave of Absence Without PayApplication/ Extension Form is available through the Service Center Fax-Back system, which can be accessed by calling 1-877-623-1955. The Form # is 3882.
  • After reading the Patient Authorization section, sign and date the form.
  • Give the signed form to your physician and have your physician complete the Attending Physician Information. The physician should retain a copy for their records and return the completed form to you. (This must be a medical doctor, we do not accept midwives; assistants; nurse practitioners; etc.)
  • Mail or Fax the completed Medical Leave of Absence Without Pay Extension Form to the McDonald’s ServiceCenter. The address and fax number can be found at the bottom of your MLWOP Application Form. Retain a copy of the form for your records.
  • The request for an extension is also subject to approval by both our medical consultants and McDonald’s. The approval process will take seven to ten business days to review your application, provided that your physician responds in a timely manner.
  • When the ServiceCenter receives the approval or denial from our medical consultants, you will be notified with a letter.

Next Step:

  • Go to Return to Work.

RETURN TO WORK FORM:

If you have been out on a leave due to your own medical condition, you must have an authorized Return to Work Form before you will be allowed to come back to work.

  • Complete the Employee Information portion of the McDonald’s Return to Work Form.
  • After reading the Employee Authorization section, sign and date the form.
  • Give the signed form to your physician and have them complete the Attending Physician Information. The physician should retain a copy for their records and return the completed form to you. (This must be a medical doctor, we do not accept midwives; assistants; nurse practitioners; etc.)
  • Provide this signed release form to your direct supervisor and send a copy to the ServiceCenter. You will not be allowed to return to active work until your supervisor receives a signed release.

It is your responsibility to remind your supervisor to notify the ServiceCenter of your return to work date and any restriction information. Your pay may be impacted if your return to work date is not called in by your supervisor. You may wish to double check to insure this has occurred.

Package 3893 2/6/2007