Fillable Certification of Health Care Provider for Employee's Serious (California)

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Certification of Health Care Provider for Employee's Serious (California)

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CalHR 754
Page 1 of 3
(rev 4/2016)
Certification of Health Care Provider for Employee's
Serious Health Condition
State of California
Family and Medical Leave Act (FMLA)
California Family Rights Act (CFRA)
Part A: For Completion by the person responsible for administering the leave program in your
department who will be the Department Contact.
Instructions: Complete Section I before giving this form to the employee.
Employee Last Name Employee First Name Employee Middle Name Last Day Worked:
Employee Classification Employee Work Unit
Department Contact Department Contact Phone
Attach a copy of the employee's job description and the essential job functions of the employee's position.
Part B: For Completion by the EMPLOYEE
Instructions to the Employee: Part A must be completed by the person responsible for administering the leave
program in your department and you must complete Part B before giving this form to your medical provider. The law
permits us to require that you submit a timely, complete, and sufficient medical certification to support your request for
FMLA/CFRA protections. Failure to provide a complete and sufficient medical certification may result in denial of your
leave request. You have 15 calendar days to return this form.
Daytime Contact Phone Number:
Regular Work Schedule
Days Nights Full Time Part Time
9/80
4/10 Other
Part C: For Completion by the HEALTH CARE PROVIDER
INSTRUCTIONS for the HEALTH CARE PROVIDER: Your patient has requested leave under FMLA/CFRA. Please
answer fully and completely all applicable parts. Several questions seek a response as to the frequency or duration of a
condition, treatment, etc. Your answers should be your best estimate based upon your medical knowledge, experience
and examination of the patient. Please be as specific as you can; terms such as “lifetime,” “unknown” or “indeterminate
may not be sufficient to determine FLMA/CFRA coverage. Please do not disclose the underlying diagnosis without
the consent of your patient. Please limit responses to the condition for which the employee is seeking leave.
Please be sure to sign and date the form on the last page
Provider Name (You may attach a business card in lieu of completing this section):
Business Address City State Zip Code
Type of Practice / Medical Specialty
Telephone Fax
Part D. Medical Facts
1 Does the patient have a serious health condition that qualifies under the categories described on the attached
sheet?
Yes No
If no, sign and date page two and return to patient.
2. If the patient has a serious health condition as defined in the attached sheet, please answer the following:
Approximate Date Condition Commenced:
3. Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
Yes No If yes, date of admission
4. Dates treated for condition:
5. Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)?
Yes No
If yes, state the frequency and expected
duration of such treatment(s):
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CalHR 754
Page 2 of 3
(rev 4/2016)
6. Is the employee unable to perform any of the job functions due to his/her medical condition?
(See attached Essential Job Functions and/or attached Job Description):
Yes No
If yes, identify the job functions the employee is unable to perform, work restrictions and probable duration:
7. Can the patient perform modified duty?
Yes No
If yes, state the type of modified duty the employee is able to perform and probable duration:
Part E: Amount of Time Needed
1. Will the employee be incapacitated for a single continuous period of time due to his/her medical condition,
including any time for treatment and recovery?
Yes No
If yes, estimate the beginning and ending dates for the period of incapacity:
2. Will the employee need to attend follow-up treatment appointments because of the employee's medical
condition?
Yes No
If yes, estimate the schedule, if any, including dates of any scheduled appointments and the time required for
each appointment, including any recovery period
3. Will the employee need to work part time or on a reduced schedule because of the employee's medical condition?
Yes No
If yes, estimate the part-time or reduced work schedule the employee needs
hour(s) per day; days per week from through
4. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job
functions?
Yes No
If yes, estimate the frequency of flare-ups and the duration of related incapacity that the patient may have over
the next 6 months (e.g., 1 episode every 3 months lasting 1-2 days):
Frequency:
times per week (s) month(s)
Duration:
hours day(s) per event
ADDITIONAL INFORMATION (Identify Question Number With Any Additional Information to Your Answers)
Signature below verifies that the information provided above is true and accurate
Printed Name of Health Care Provider
Health Care Provider Signature
Date
Employee Last Name Employee First Name Employee Middle Name
CalHR 754
Page 3 of 3
(rev 4/2016)
Employee Last Name Employee First Name Employee Middle Name
Dear Health Care Provider,
Do NOT provide the employee's diagnosis.
The employee has requested leave under the Federal and/or California family and medical leave statutes for his or her
own serious health condition.
Thank you for your assistance.
Definition of a Serious Health Condition
Serious health condition is any illness, injury, impairment, physical or mental condition that involves:
1. Any period of incapacity or treatment in connection with or consequent to an overnight stay in a hospital,
hospice, or residential medical care facility; or
2. Continuing treatment by a health care provider for one or more of the following:
a. Any period of incapacity due to pregnancy, for prenatal care.
b. Any period of incapacity due to a chronic serious health condition that:
i. Requires periodic ( at least two visit per year) visits for treatment
ii. Continues over an extended period of time; and
iii. May cause episodic rather than a continuing period of incapacity (e.g., asthma,
diabetes, epilepsy, etc.)
3. Any period of incapacity which is long-term due to a condition for which treatment may not be effective (e.g.,
Alzheimer's disease)
4. Any period of absence required to receive multiple treatments (including the period of recovery) either for
restorative surgery after an accident or other injury, or for a chronic condition that would likely result in a
period of incapacity of more than three consecutive calendar days in the absence or medical intervention
such as cancer (chemotherapy, radiation, etc., or kidney disease (dialysis) or severe arthritis (physical
therapy).
A Serious Health Condition Is Generally Not:
1. Allergies, stress, or substance abuse unless inpatient hospital care is provided, or the patient is incapacitated
for more than three calendar days and is under the continuing care of a health care provider, or the patient
has a serious long-term health conditions; or
2 Voluntary treatment or surgery inpatient hospital care is required.
A Health Care Provider Is:
Department of Labor regulations for the Family and Medical Leave Act define a “health care provider” as a
1. doctor of medicine or osteopathy, podiatrist, dentist, chiropractor, clinical psychologist, optometrist, nurse practitioner,
nurse-midwife, or clinical social worker, physicians assistant, who is authorized to practice by the State and performing
within the scope of their practice as defined by State law, or a Christian Science practitioner.
2. any provider the employee's group health plan will accept certification of a serious health condition to substantiate a
claim for benefits.
PRIVACY NOTICE
The Information Practices Act of 1977 (Civil Code Section 1798.17) and the Federal Privacy Act (Public Law 93-579) requires this
notice be provided when collecting personal information from individuals.
Information requested on this form is used by your department for purposes of determining your eligibility for FMLA/CFRA benefits. It
is mandatory to furnish all information requested on this form. Failure to provide the mandatory information may result in a delay in
processing your request.
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Certification of Health Care Provider for Employee's Serious (California)

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Completed 30 June 2021

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