UNIVERSITY OF CINCINNATI Family and Medical Leave Act (FMLA) and MEDICAL LEAVE
CERTIFICATION OF HEALTH CARE PROVIDER FORM and INSTRUCTIONS
INSTRUCTIONS FOR EMPLOYEE – COMPLETE SECTION 1
INSTRUCTIONS FOR HEALTH CARE PROVIDER: - COMPLETE SECTION 2
Give this form to the health care provider and ask that he/she return it to the
address below within 15 calendar days.
Return the completed form to UC University Health Services (address/fax below)
within 15 calendar days of receipt.
Contact the UC HR Department at 513 556-6381 with any questions.
Contact UC University Health Services at 513 584-4457 with any questions.
SECTION 1. EMPLOYEE INFORMATION and AUTHORIZATION – Please print.
Employee Name:
Employee ID/M#:
Dept/Org Unit Name:
Supervisor/BA Name:
Employee DOB:
Job Title:
Supervisor/BA Phone #
Phone # (Home or Cell):
Phone # (Work):
Email (Home):
Patient is:
employee
spouse
parent
child If child, give DOB:______________________ other (list): _______________________
I hereby authorize release of the information below to University of Cincinnati University Health Services.
______________________________________________________________
Signature
________________________________________
Date
SECTION 2. TO BE COMPLETED BY HEALTH CARE PROVIDER
HEALTH CARE PROVIDER: Please read the definitions below and check ALL that apply. A ‘Serious Health Condition’ is an illness, injury, impairment
or physical or mental condition that involves any of the following. Please () check all that apply. **Be as specific as you can; terms such as
“lifetime” “unknown,” may not be sufficient to determine FMLA coverage. Do not provide information about genetic tests, as defined in 29 C.F.R.
§ 1635.3(f), genetic services, as defined in 29 C.F.R. § 1635.3(e), or the manifestation of disease or disorder in the employee’s family members, 29
C.F.R. § 1635.3(b).
Inpatient care (i.e., overnight stay) in a hospital, hospice or residential medical care facility.
Pregnancy/prenatal care
Eligible Family Member. If time off is to care for a family member, explain the care needed and why such care is medically necessary:
Incapacity*** of more than three consecutive days involving two or more treatments by a health care provider or one treatment that results in
a regimen of continuing treatment (i.e., prescription medication or physical therapy requiring special equipment). ***Incapacity means the
inability to work, attend school or perform regular daily activities.
Chronic conditions continuing over a period of time that require periodic treatment and may cause episodic periods of incapacity.
Permanent long term conditions resulting in incapacity and requiring continuing supervision by health care provider (e.g., Alzheimer’s, severe
stroke).
Multiple treatments by a health care provider for either restorative surgery or for a condition that would likely result in a period of incapacity
of more than three days in the absence of medical intervention (e.g., cancer and chemotherapy treatment).
None of the above applies.
Patient’s Name:
Indicate date serious health condition began:
The absence from work requested is for a serious health condition as indicated above: YES NO
Describe the medical facts which support your certification:
Indicate () type of leave that is needed. Check all that apply and provide COMPLETE responses:
Intermittent to attend follow up appointments (dates of and time required for appointments) or for episodic flare ups (**estimate frequency
and duration of incapacity) for the employee to be absent from work. Employee will need time off of no more than 3 consecutive days. The
need for this time off is from: ________________ through______________. Intermittent leave is needed for:  appointments episodic
exacerbations. Provide estimated frequency (i.e. ,1 to 2 times per month): __________________________________and duration (i.e., 1 to 2 days
per episode: _____________________________________.
Continual: The employee will be off for at least 3 consecutive days. The need for this leave is continual from: ___________________through
__________________. Estimated date of return:_________________________.
Signature of Health Care Provider
Print Name of Health Care Provider
Address
Telephone Number
RETURN ORIGINAL TO: University Health Services - University of Cincinnati, M. L. #0460 - Cincinnati, OH 45267-0460
Phone: 513-584-4457 Fax: 513-584-2222
Form CHCP-Rev: 06/15