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Certification Of Health Care Provider For Employees Serious Health Condition WH-380-E - Official Federal Forms

Certification Of Health Care Provider For Employees Serious Health Condition Form. This is a national form and can be used in US Dept Of Labor .
 Fillable pdf Last Modified 9/16/2015
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Certification of Health Care Provider for Employee's Serious Health Condition (Family and Medical Leave Act) U.S. Department of Labor Wage and Hour Division DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT OMB Control Number: 1235-0003 Expires: 5/31/2018 SECTION I: For Completion by the EMPLOYER 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. Please complete Section I before giving this form to your employee. Your response is voluntary. While you are not required to use this form, you may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306-825.308. Employers must generally maintain records and documents relating to medical certifications, recertifications, 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, and in accordance with 29 C.F.R. § 1635.9, if the Genetic Information Nondiscrimination Act applies. Employer name and contact: __________________________________________________________________ Employee's job title: _____________________________ Regular work schedule: _______________________ Employee's essential job functions: _____________________________________________________________ __________________________________________________________________________________________ Check if job description is attached: _____ SECTION II: For Completion by the EMPLOYEE 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 FMLA leave 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. 20 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 name: __________________________________________________________________________________ First Middle Last SECTION III: For Completion by the HEALTH CARE PROVIDER 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. Do not provide information about genetic tests, as defined in 29 C.F.R. § 1635.3(f), genetic services, as defined in 29 C.F.R. § 1635.3(e), or the manifestation of disease or disorder in the employee's family members, 29 C.F.R. § 1635.3(b). Please be sure to sign the form on the last page. Provider's name and business address: ___________________________________________________________ Type of practice / Medical specialty: ____________________________________________________________ Telephone: (________)____________________________ Fax:(_________)_____________________________ Page 1 Form WH-380-E Revised May 2015 American LegalNet, Inc. 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 so, 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 (e.g., physical therapist)? ____No ____Yes. If so, state the nature of such treatments and expected duration of treatment: ________________________________________________________________________________________ 2. Is the medical condition pregnancy? ___No ___Yes. If so, expected delivery date: ____________________ 3. Use the information provided by the employer in Section I to answer this question. f the employer fails to I 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 so, 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 symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment): ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ______________________________________________________________________________________
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