Non fmla medical certification form

    • [DOC File]2002—2003 Benefits Election - LTU

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      Non-FMLA Medical Certification (HealthCare Provider’s Statement) Form #3110. Section I: Employer Information . Lawrence Technological University. Office of Human Resources. 21000 West Ten Mile Road. Southfield, MI 48075 Phone: 248.204.2150. Confidential Fax: 248.204.2118 Patient’s Information . Print Name (Last, First, Middle Initial): Employee’s Job Title: Employee’s Essential Job ...

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    • [DOC File]CS-1835_Non-FMLA_Medical_Certification_by_Physician

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      NON-FMLA MEDICAL CERTIFICATION BY PHYSICIAN OR PRACTITIONER. SECTION I ( Authorization to Release Medical Information I authorize my (or my minor child’s) attending physician or practitioner to release the information requested below in Section II to the employee’s employer regarding my (or my minor child’s) physical or mental condition. This information will only be used as necessary …

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    • [DOC File]UNPAID LEAVE OF ABSENCE

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      FMLA. Medical (non-FMLA): Medical certification with . diagnosis and expected length of disability MUST BE FORWARDED to the appropriate personnel office . Personal (If personal leave request is for caring for an immediate family member, you must submit a completed . Medical Certification – Family Member. form, per the Family and Medical Leave Policy) Military. FTE or % of leave time. Other ...

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    • [DOCX File]ADA aCCOMMODATION MEDICAL CERTIFICATION fORM

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      INSTRUCTIONS FOR COMPLETING THE MEDICAL CERTIFICATION FORM. Under the Americans with Disabilities Act (ADA), a qualified employee with a disability may request reasonable accommodations by engaging the interactive process with their employer. During the interactive process, if appropriate, an employer may request medical documentation in support of an employee’s disability, …

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    • [DOC File]CERTIFICATION NOT RECEIVED - University of California ...

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      Enclosed is another [name of form(s) not received]. [This/These] form(s) must be completed and should be returned to _____ as soon as possible and preferably within 7 calendar days of this request. Unless and until the required documentation is provided, your absences will not be designated as FML. Without that designation, your absences will not be protected FML and may be considered unapproved.

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    • [DOC File]MEDICAL CERTIFICATION FOR SERIOUS HEALTH CONDITION FOR ...

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      MEDICAL CERTIFICATION FOR SERIOUS HEALTH CONDITION FOR EMPLOYEE (Non FMLA/CFRA Leave) SECTION I: For Completion by the EMPLOYER . INSTRUCTIONS to the EMPLOYER: An employer may require an employee seeking a 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 …

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    • fmla_certification_of_health_care_provider_attachment3.PDF

      Once completed, please submit this form to your supervisor. Failure to do so may result in the delay or denial of your use of FMLA. Employee Name People First ID# Home Telephone Number: () Circuit/Section: Patient’s Name (if different from employee): Patient’s Relationship to Employee: MEDICAL INFORMATION The Genetic Information Nondiscrimination Act of 2008 (GINA)

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    • [DOCX File]FMLA Notification Letter

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      FMLA Denial Letter. DATE. Employee Name. Employee Address. CITY, ST, ZIP . Dear EMPLOYEE, This letter is intended solely as notice that your current absence is not eligible for coverage under the Family and Medical Leave Act of 1993 (FMLA). It is not intended as a statement regarding your eligibility to be absent from the workplace. At this time, your request for FMLA coverage is denied. The ...

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    • [DOC File]Request for Leave of Absence - LTU

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      *For a Non-FMLA Medical Leave, also submit the Non-FMLA Medical Certification Form #3110. Leave Period Taken: Consecutively Intermittently Reduced leave schedule Last Day at Work First Date of Leave Last Date of Leave Expected Return to Work Date Explain reason for leave of absence (attach additional sheets of explanation, if necessary and/or military orders) : Leave Time Usage (Staff and Non ...

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    • [DOC File]FAMILY AND MEDICAL LEAVE - Human Resources

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      It is the policy of the University to require medical certification to document that the illness of the employee or family member meets the qualifications of a “serious health condition” as outlined by the Family and Medical Leave Act regulations. The completed certification form should be returned to the Human Resource Office 30 days prior to the start of the leave or within fifteen days ...

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