ࡱ> Z\Y *bjbjWW X==\![&&iiiii}}}8\\}"".mdX)))aaa!!!!!!!P#%!i4]]44!ii))4!bbb4i)i)!b4!bb:] , )p\Q}v !!0"" R&2l& &i a0"beaaa!!aaa""4444&aaaaaaaaa& /: 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 employees 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 and you may not require that the health care provider disclose the underlying diagnosis of the serious health condition involved. Employers must generally maintain records and documents relating to medical certifications, recertifications, or medical histories of employees as confidential medical records in separate files/records from the usual personnel files and in accordance with applicable law. Employer name and contact: _____________________________________________________ Employees job title: ___________________________ Regular work schedule: _____________ Employees essential job functions (or note on attached job description): _____________________________________________________________________________ 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 health care provider. The employer may require that you submit a timely, complete, and sufficient medical certification to support a request for a medical leave of absence due to your own serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of legal protections. Failure to provide a complete and sufficient medical certification may result in a denial of your leave of absence request. You have 15 calendar days to return this form. Your name: ________________________________________________________________________ First Middle Last SECTION III: For Completion by the HEALTH CARE PROVIDER INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested a medical leave of absence. 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 leave eligibility. Limit your responses to the condition for which the employee is seeking leave. 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 an individual or family member of the individual, except as specifically allowed by this law. 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 individuals family medical history, the results of an individuals or family members genetic tests, the fact that an individual or an individuals family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individuals family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. Medical Certification for Employee To be completed by the patients health care provider: 1. Employees Name: ________________________________________ 2. Company: ___________________________________________ 3. Date medical condition or need for treatment commenced: __________________________ (Note: The health care provider is not to disclose the underlying diagnosis without the consent of the patient.) 4. Probable duration of medical condition or need for treatment:_____________________________________________________________________ 5. The attached sheet describes what is meant by a serious health condition. Does the patients condition qualify under any of the categories described? FORMCHECKBOXYesFORMCHECKBOXNo 6. If the certification is for the serious health condition of the employee, please answer the following: a. Is the employee able to perform work of any kind? FORMCHECKBOXYesFORMCHECKBOXNo b. Is the employee able to perform the essential functions of the employees position? Answer after reviewing the employees job description that includes the essential functions of the employees position. FORMCHECKBOXYesFORMCHECKBOXNo If not, identify functions unable to perform. 7. Please answer the following question only if the employee is asking for intermittent leave or a reduced work schedule: a. Is it medically necessary for the employee to be off work on an intermittent basis or to work less than the employees normal work schedule to deal with the serious health condition of the employee? FORMCHECKBOXYesFORMCHECKBOXNo b. If the answer to question a is yes, please indicate the estimated number of health care provider visits, and/or estimated duration of medical treatment, either by the health care provider or another provider of health services, upon referral from the health care provider. Estimate: _________________________________________________________________ 8. __________________________________________________ __________ Signature of Health Care Provider Date Address:______________________________________ ______________________________________ Phone #______________________________________ Definitions (Attach to Medical Certification) A Serious Health Condition means an illness, injury, impairment, or physical or mental condition that involves one of the following: Hospital Care Inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical care facility, including any period of incapacity or subsequent treatment in connection with or consequent to such inpatient care. Absence Plus Treatment (a) A period of incapacity of more than three consecutive calendar days (including any subsequent treatment or period of incapacity relating to the same condition), that also involves: (1) Treatment (two or more times by a health care provider, by a nurse or physicians assistant under direct supervision of a health care provider, or by a provider of health care services (e.g., physical therapist) under orders of, or on referral by, a health care provider), or (2) Treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment under the supervision of the health care provider. Chronic Conditions Requiring Treatment A chronic condition which: (a) Requires periodic visits for treatment by a health care provider, or by a nurse or physicians assistant under direct supervision of a health care provider, (b) Continues over an extended period of time (including recurring episodes of a single underlying condition); and (c) May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.). Permanent/Long-term Conditions Requiring Supervision A period of incapacity which is permanent or long-term due to a condition for which treatment may not be effective. The employee or family member must be under the continuing supervision of, but need not be receiving active treatment by, a health care provider. Examples include Alzheimers, a severe stroke, or the terminal stages of a disease. 5. Multiple Treatments (Non-Chronic Conditions) Any period of absence to receive multiple treatments (including any period of recovery therefrom) by a health care provider or by a provider of health care services under orders of, or on referral by, a health care provider, either for restorative surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity of more than three consecutive calendar days in the absence of medical intervention or treatment such as cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), or kidney disease (dialysis).     PAGE  2011 Silvers HR, LLC Page  PAGE 2 of  NUMPAGES 4 Form #4802: Rev. 2 04/14/11 2010 Silvers HR, LLC Page  PAGE 1 of  NUMPAGES 4 Form #4802: 10/8/09  !#(*2368@INTVWYZվwsYA/hh'5B*CJOJQJ\^JaJph2 *h,h'5B*CJOJQJ\^JaJphh'h'B*ph,h_Vh'5B*CJOJQJ^JaJph&h5B*CJOJQJ^JaJph&hcA5B*CJOJQJ^JaJph,h hh h5B*CJOJQJ^JaJph&h'5B*CJOJQJ^JaJph,h_Vh'5B*CJOJQJ^JaJph@VWXY  [ ! 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L^`LhH. ^`hH. qq^q`hH. ALA^A`LhH. ^`hH. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.0j+TlL                 -,&4 e $W!')"._24-B69P : <cA2\ h. jun~|9%8oy _1GX"%DS!7uvoGtKu'6S3~\!^!@"h@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial5. .[`)TahomaA$BCambria Math"1h ' 'b<b<!x24K!K!3qHP?92!xx?MEDICAL CERTIFICATION FOR SERIOUS HEALTH CONDITION FOR EMPLOYEEJoanne ChristmanMary  Oh+'0  < H T `lt|@MEDICAL CERTIFICATION FOR SERIOUS HEALTH CONDITION FOR EMPLOYEEJoanne Christman Normal.dotmMary2Microsoft Office Word@@^`@@b՜.+,0, hp  Toshiba<K! @MEDICAL CERTIFICATION FOR SERIOUS HEALTH CONDITION FOR EMPLOYEE Title  !"#$%&'()*+,./012346789:;<=>?@ABCDEFGHJKLMNOPRSTUVWX[Root Entry F m]Data -1Table5&WordDocumentXSummaryInformation(IDocumentSummaryInformation8QCompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q