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FMLA Medical Certification (Family Member) with Tip Sheet - ComplyRight Mobile App

Updated to comply with the most recent FMLA regulations effective March 8, 2013

Use this attorney-developed form when an employee requests time off to care for an immediate family member with a serious health condition. FMLA Certifications are used to verify an employee’s need for FMLA leave and the existence of an FMLA-qualifying event. They help you gather the information you need to either grant or deny FMLA leave, without violating an employee’s privacy rights or overstepping legal boundaries. In each scenario, give your employee the blank certification form within five business days after learning about his or her need for leave, and allow the employee at least 15 days to return it.

Need printed FMLA Forms? Visit G.Neil for a printed version of the FMLA Medical Certification (Employee) Form.

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Take a peek inside the FMLA Medical Certification (Family Member) with Tip Sheet - ComplyRight Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    SECTION I: For Completion by the EMPLOYER

  • Ico statictext

    INSTRUCTIONS: The Family and Medical Leave Act (FMLA) provides that you, as an employer, may requ...

  • Ico multiline

    Employer name and contact:

  • Ico statictext

    SECTION II: For Completion by the Employee

  • Ico statictext

    INSTRUCTIONS: Please complete Section II before giving this certification to your family member's...

  • Ico statictext

    PLEASE DO NOT PROVIDE GENETIC INFORMATION: The Genetic Information Nondiscrimination Act of 2008 ...

  • Ico statictext

    Your name:

  • Ico textbox

    First

  • Ico textbox

    Middle

  • Ico textbox

    Last

  • Ico statictext

    Name of family member for whom you will provide care:

  • Ico textbox

    First

  • Ico textbox

    Middle

  • Ico textbox

    Last

  • Ico textbox

    Relationship of family member to you:

  • Ico date

    If family member is your son or daughter, date of birth:

  • Ico multiline

    Describe care you will provide to your family member and estimate leave needed to provide care:

  • Ico signature

    Employee signature:

  • Ico date

    Date:

  • Ico statictext

    SECTION III: For Completion by HEALTHCARE PROVIDER

  • Ico statictext

    INSTRUCTIONS: The employee listed on the previous page has requested leave under the FMLA to care...

  • Ico statictext

    PLEASE DO NOT PROVIDE GENETIC INFORMATION: The Genetic Information Nondiscrimination Act of 2008 ...

  • Ico multiline

    Provider’s name and business address:

  • Ico multiline

    Type of practice/medical specialty:

  • Ico textbox

    Telephone:

  • Ico textbox

    Fax:

  • Ico date

    1. Approximate date condition began:

  • Ico multiline

    Probable duration of condition:

  • ...and More!

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