(Family and Medical Leave Act of 1993)
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The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking military family leave due to a serious injury or illness of a covered servicemember to submit a timely, and complete certification providing sufficient facts to support the request for leave.
SECTION I: For Completion by the EMPLOYEE and/or the COVERED SERVICEMEMBER for whom the Employee Is Requesting Leave The employee or covered servicemember should complete Section I before having Section II completed. Your response is required to obtain or retain the benefit of FMLA-protected leave. Failure to do so may result in a denial of an employee’s FMLA request. You have 15 calendar days to return this form to your supervisor.
SECTION II: For Completion by a UNITED STATES DEPARTMENT OF DEFENSE (“DOD”) HEALTH CARE PROVIDER or a HEALTH CARE PROVIDER who is either: (1) a United States Department of Veterans Affairs (“VA”) health care provider; (2) a DOD TRICARE network authorized private health care provider; or (3) a DOD non-network TRICARE authorized private health care provider.
INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed on Page 2 has requested leave under the FMLA to care for a family member who is a member of the Regular Armed Forces, the National Guard, or the Reserves who is undergoing medical treatment, recuperation, or therapy, is otherwise in outpatient status, or is otherwise on the temporary disability retired list for a serious injury or illness. For purposes of FMLA leave, a serious injury or illness is one that was incurred in the line of duty on active duty that may render the servicemember medically unfit to perform the duties of his or her office, grade, rank, or rating.
A complete and sufficient certification to support a request for FMLA leave due to a covered servicemember’s serious injury or illness includes written documentation confirming that the covered servicemember’s injury or illness was incurred in the line of duty on active duty and that the covered servicemember is undergoing treatment for such injury or illness by a health care provider listed above. 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.
SECTION I: For Completion by the EMPLOYEE and/or the COVERED SERVICEMEMBER for whom the Employee Is Requesting Leave: (This section must be completed first before any of the below sections can be completed by a health care provider.)
PART A: EMPLOYEE INFORMATION
Name and Address of Employer (this is the employer of the employee requesting leave to care for covered servicemember):
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Name of Employee Requesting Leave to Care for Covered Servicemember:
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First Middle Last
Name of Covered Servicemember (for whom employee is requesting leave to care):
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First Middle Last
Relationship of Employee to Covered Servicemember Requesting Leave to Care:
_____Spouse _____Parent _____Son _____Daughter _____Next of Kin
PART B: COVERED SERVICEMEMBER INFORMATION
(1) Is the Covered Servicemember a Current Member of the Regular Armed Forces, the National Guard or Reserves? _____Yes _____No
If yes, please provide the covered servicemember’s military branch, rank and unit currently assigned to:
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Is the covered servicemember assigned to a military medical treatment facility as an outpatient or to a unit established for the purpose of providing command and control of members of the Armed Forces receiving medical care as outpatients (such as a medical hold or warrior transition unit)? _____Yes _____No
If yes, please provide the name of the medical treatment facility or unit: ________________________________
(2) Is the Covered Servicemember on the Temporary Disability Retired List (TDRL)? _____Yes _____No
PART C: CARE TO BE PROVIDED TO THE COVERED SERVICEMEMBER
Describe the Care to Be Provided to the Covered Servicemember and an Estimate of the Leave Needed to Provide the Care:
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SECTION II: For Completion by a United States Department of Defense (“DOD”) Health Care Provider or a Health Care Provder who is either: (1) a United States Department of Veterans Affairs (“VA”) health care provider; (2) a DOD TRICARE network authorized provate health care provider; or (3) a DOD non-network TRICARE authorized private health care provider: If you are unable to make certain of the military-related determinations contained below in Part B, you are permitted to rely upon determinations from an authorized DOD representative (such as a DOD recovery care coordinator). Please ensure that Section I above has been completed before completing this section.) Please be sure to sign the form on the last page.
PART A HEALTHCARE PROVIDER INFORMATION
Health Care Provider’s Name and Business Address:
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Type of Practice/Medical Specialty: _______________________________________________________________
Please state whether you are either: (1) A DOD health care provider; (2) a VA health care provider; (3) a DOD TRICARE network authorized private health care provider; or (4) a DOD non-network TRICARE authorized private health care provider: ___________________________________________________________________________
Telephone: ( ) _____________ Fax: ( )_____________ Email:____________________________________
PART B MEDICAL STATUS
(1) Covered Servicemember’s medical condition is classified as (Check One of the Appropriate Boxes):
(VSI) Very Seriously Ill/Injured — Illness/Injury is of such a severity that life is imminently endangered. Family members are requested at bedside immediately. (Please note this is an internal DOD casualty assistance designation used by DOD healthcare providers.)
(SI) Seriously Ill/Injured — Illness/injury is of such severity that there is cause for immediate concern, but there is no imminent danger to life. Family members are requested at bedside. (Please note this is an internal DOD casualty assistance designation used by DOD healthcare providers.)
OTHER Ill/Injured — a serious injury or illness that may render the servicemember medically unfit to perform the duties of the member’s office, grade, rank, or rating.
NONE OF THE ABOVE (Note to Employee: If this box is checked, you may still be eligible to take leave to care for a covered family member with a “serious health condition” under § 825.113 of the FMLA. If such leave is requested, you may be required to complete DOL FORM WH-380 or an employer-provided form seeking the same information.)
(2) Was the condition for which the Covered Servicemember is being treated incurred in line of duty on active duty in the armed forces? ____Yes _____No
(3) Approximate date condition commenced:________________________________________________________
(4) Probable duration of condition and/or need for care:________________________________________________
(5) Is the covered servicemember undergoing medical treatment, recuperation, or therapy? ____Yes ____No
If yes, please describe medical treatment, recuperation or therapy:
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PART C: COVERED SERVICEMEMBER’S NEED FOR CARE BY FAMILY MEMBER
(1) Will the covered servicemember need care for a single continuous period of time, including any time for treatment and recovery? ____Yes ____No
If yes, estimate the beginning and ending dates for this period of time: _________________________________
(2) Will the covered servicemember require periodic follow-up treatment appointments?____Yes ____No
If yes, estimate the treatment scheduled:_________________________________________________________
(3) Is there a medical necessity for the covered servicemember to have periodic care for these follow-up treatment appointments? ____Yes ____No
(4) Is there a medical necessity for the covered servicemember to have periodic care for other than scheduled follow-up treatment appointments (e.g., episode flare-ups of medical condition)? ____ Yes ____ No.
If yes, please estimate the frequency and duration of the periodic care:
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Signature of Health Care Provider: Date: