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Health Care

This document provides instructions and a form for a health care provider to complete to certify an employee's need for leave under the Family and Medical Leave Act (FMLA) due to their own serious health condition. The form requests information including diagnosis, dates of treatment, whether leave is medically necessary, expected duration and schedule of leave. It requires the provider to certify the condition, expected start and end dates of the leave, and their contact information.

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518 views1 page

Health Care

This document provides instructions and a form for a health care provider to complete to certify an employee's need for leave under the Family and Medical Leave Act (FMLA) due to their own serious health condition. The form requests information including diagnosis, dates of treatment, whether leave is medically necessary, expected duration and schedule of leave. It requires the provider to certify the condition, expected start and end dates of the leave, and their contact information.

Uploaded by

Mike
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Health Care Provider Certification for the Family and Medical Leave Act (FMLA)

Employee's Own Serious Health Condition


Employee Section
Important!
1. Your health care provider must complete all questions on this form.
2. You must call the Leave of Absence and Accommodations (LOAA) team at 1-888-892-7180, option 1, to initiate your leave
of absence before you submit this form. Failure to contact the LOAA team to report your leave without justification may
result in delay or denial or leave.
3. Fax this completed form to 1-847-554-1812, email to AmazonAM@ .com, or mail to LOAA team,

Name (Print) Employee ID


Health Care Provider Section
1. Check the serious health condition(s) requiring this employee to take a leave of absence: (See definitions page for more information.)
Absence Plus Treatment Chronic Conditions Requiring Treatment Hospital Care Pregnancy
Permanent/Long-Term Conditions Requiring Supervision Multiple Treatments (Nonchronic Conditions)
2. List the date(s) you treated the employee for the above condition(s):
First Visit: Most Recent Visit: Next Scheduled Visit:
3. Is/was it medically necessary for the employee to miss work due to the above condition(s)? No Yes
4a. Describe the medical facts that support the serious health condition(s) indicated in #1 (patient complaints, symptoms,
examination or diagnostic test/study findings, prescribed medications): (not required for employees working in California)

4b. Diagnosis(es): Provide the serious health condition(s):


Primary Diagnosis: Co-morbid Diagnosis (include if it impacts work capacity):
5a. The employee needs/needed to miss work:
Continuously-An uninterrupted absence for a single illness or injury because the employee can/could not do his or her job
Intermittently-Occasional absences due to a single illness or injury (includes reduced schedule)
5b. If intermittent leave is expected and/or has occurred, check one and provide the related information:
Reduced Work Schedule
How many days does/did the employee need to miss work (e.g., 1 day a week)?__________________________________
How many hours does/did the employee need to miss work each day (e.g., 5 hours)? ______________________________
Unplanned, Unknown, or as Medically Necessary
How often does/did this employee need to be away from work (e.g., twice a month)? ______________________________
How long does/did this employee need to be away from work each absence (e.g., 4 hours)? _________________________
Note: The employee is required to provide a requested leave schedule to his or her manager
6. Certification Start Date: Date employee is/was first unable 7. Certification End Date: Date employee can/could return to
to work due to the serious health condition(s) above: work at his or her normal schedule:
_____ / _____ / _______ _____ / _____ / _______
mm dd yyyy mm dd yyyy
If intermittent, use the first date of the most recent period of absence. If chronic or permanent condition(s), the return date will be no greater than one
year after the leave start date
Health Care Provider Acknowledgment
Name (Print): __________________________________ Type of Practice/Specialization: _______________________________
Address:_____________________________________________________________________ Phone: ____________________

Signature: Date:

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