Certification of Health Care Provider for U.S. Department of Labor Employees Serious Health Condition (Family and Medical Leave Act)
The employee seeks to request for Family and Medical Leave Act leave due to one’s serious conditions.Download
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Page 1 Form WH-380-E Revised May 2015 Certification of Health Care Provider for U.S. Department of Labor Employee’s Serious Health Condition Wage and Hour Division (Family and Medical Leave Act) 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 I I: 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 S ECTION I II: 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:(_________)_____________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ 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 ho spital, hospice, or residential me dical care facility ? ___ No ___ Yes. If so, dates of ad mission: Date(s) you tr eated the patient for condition: Will the patient need to have treatment visits at least twice per y ear 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 treatme nt (e.g. , phy sical 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 em ployer in Secti on I to an swer this question. If the em ploy er fail s to provide a list of the em ployee’s essential functions or a job descripti on, 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 func tions due to the condition: ____ No ____ Yes. If so, identify the job functi ons the em ployee is unable to perform: 4. Describe other relevant medical facts, if any, rela ted to the condition for which the employee seeks leave (such medical facts may inc lude symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment): Page 2 CONTINUED ON NEXT PAGE Form WH-380-E Revised May 2015 ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ PART B: AMOUNT OF LEAVE NEEDED 5. Will the employee be incapacitated for a single contin uous period of time due to his/her medical condition, including any time for treatment and recovery? ___ No ___Yes. If so, estimate the beginning and ending dates for the period of incapacity: _______________________ 6. Will the employee need to attend follow-up treatme nt appointments or work part-time or on a reduced schedule because of the employee’s me dical condition? ___No ___Yes. If so, are the treatments or the reduced num ber of hours of work m e dically necessary? ___No ___Yes. Estima te treatment schedule, if any, incl uding the dates of any scheduled appointments and the time required for each appointment, incl uding any recovery period: Estimate the part-time or reduced work schedule the e mploy ee needs, if any : ____ ______ hour(s) per d ay ; ___ ___ __ __ days per week from _____________ through ____ _________ 7. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job functions? ____ No ____ Yes. Is it medically necessary for the empl oyee to be absent from work during the flare-ups? ____ No ____ Yes. If so, explain: Based upon the patient’s medical histo ry and your knowledge of t he medical condition, estimate the frequency of flare-ups and the duration of related inca pacity that th e patient may have over the next 6 months (e.g., 1 episode every 3 months lasting 1-2 days): Frequency : _____ times pe r _____ week(s) _____ month(s) Duration: _____ hours or ___ day(s) per episode ADDITIONAL INFORMATION: IDENTIFY QUE STION NUM BER WITH YOUR ADDITIONAL ANSWER. Page 3 CONTINUED ON NEXT PAGE Form WH-380-E Revised May 2 015 __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________ __________________________________________ Signature of Health Care Provider Date PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT If submitted, it is mandatory for employers to retain a copy of th is disclosure in their records for three years. 29 U.S.C. § 2616; 29 C.F.R. § 825.500. Persons are n ot required to respond to this collection of information unless it displays a currently valid OMB control nu mber. The Department of Labor estimates that it will take an average of 20 minutes for respondents to complete this collection of information, including the time for reviewing inst ructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection information, in cluding suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC 20210. DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT. Page 4 Form WH-380-E Revised May 2015Relevant article from our knowledge database
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Employees may take as much as a 12-week leave as much as a single year after a young child is put through adoption or foster care with an employee. A worker who is not able to work or carry out other regular, daily pursuits due to pregnancy has a significant health condition. In these instances, an employer may ask for one more certification to set up such additional needs. It's usually an employer or doctor who fills out a lot of the form. To put it differently, a worker who simply requires a week off due to illness without seeking treatment doesn't have this kind of severe health condition. Additionally, the business offers healthcare specialists and nurses based on the needs of the employee. All companies in California are covered via this program irrespective of the range of employees they have.