Fax
To: From:
Associate Service Center (AssociateServiceCenter@mvwc.com)
Fax: (407) 418-7700 Pages:
Phone: (855) 477-2123 Date:
Re: Certification Request for CC:
Alexis Aguilar
To Whom It May Concern:
Please complete the Certification of Health Care Provider Form and return to: (407) 418-7700
If you have any questions, you may contact (855) 477-2123
Thank you.
Request for Medical Leave Form
The purpose of this form is to assist the Company in determining whether an associate
has a serious health condition and/or disability requiring medical leave.
Alexis Aguilar
Patient Name: __________________________________________________________
First Middle Last
Job Title: Housekeeper
____________________________________________
Job Description:
Cleans interior and immediate areas around assigned units in accordance with inspection checklists. Ability to
stand & exert well-paced mobility for up to 4 hrs in length. Ability to lift up to 75 lbs & push & pull carts &
equipment weighing up to 250 lbs on a regular basis. Ability to bend, stoop, squat & stretch to fulfill cleaning
tasks.
The Genetic Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered
by GINA Title II from requesting, or requiring, genetic information of an individual or family
member of the individual, except as specifically allowed by this law. To comply with this law, we
are asking that you not provide any genetic information when responding to this request for
medical information. " Genetic information ," as defined by GINA, includes an individual's family
medical history, the results of an individual's or family member's genetic tests, the fact that an
individual or an individual's family member sought or received genetic services, and genetic
information of a fetus carried by an individual or an individual's family member or an embryo
lawfully held by an individual or family member receiving assistive reproductive services.
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To be completed by the employee requesting medical leave:
Employee Name: ________________________________________________________
First Middle Last
Job Title: _______________ Location:____________________________
Please answer the following questions to assist us in understanding the
basis and nature of your request for a medical leave (attach additional
sheets if necessary). Medical documentation to support your request is
required.
1. Please describe as completely and specifically as possible the medical leave (e.g.
intermittent, continuous and/or reduced schedule) you are requesting for your serious
health condition. Include the estimated amount of time away from work you expect to
need. If the condition is pregnancy or childbirth related, please state the date or
expected date of delivery.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
2. What are the limitations caused by your condition(s) that you are currently
experiencing? What specific job function(s) are you unable to perform because of your
condition? Please provide as much detail as you believe is relevant.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
4. Please indicate the duration of the requested medical leave.
_____________________________________________________________________
_____________________________________________ ______________
Employee’s Signature Date
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TO HEALTH CARE PROVIDER: Please complete this certification in full.
We are making this request pursuant to authorization from your patient who is our
employee. This form is for employees who need medical leave for a serious health
condition, pregnancy, childbirth and related medical conditions.
1. Please answer the appropriate question below as to whether the patient has a
qualifying medical condition. Please skip to question No. 2 if the condition is
pregnancy, childbirth or a related medical condition.
Note to provider, state and local law varies on the precise definition of what is a
qualifying medical condition.
• In California, the question is does the patient have a physical or mental
impairment that limits a major life activity. ___ YES ____ NO
• In New York City, the question is whether the patient has any physical, medical
or psychological impairment or history or such impairment. ___ YES ____ NO
• In New Jersey, the question is whether the patient has a physical disability,
infirmity, malformation, or disfigurement, physical illness or disease, mental,
psychological or developmental disability that either prevents the normal exercise
of any bodily or mental functions or can be shown to exist through clinical or
diagnostic tests. It also includes paralysis, amputation, epilepsy, visual/hearing
impairments, speech impediments, AIDS, HIV infection, and blood traits.
___ YES ____NO
• In all other locations, describe the relevant medical facts, if any, related to the
condition for which the employee seeks leave:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
2. If the condition is pregnancy, childbirth or a related medical condition, indicate the
date (or expected date) of delivery and the restrictions caused by the condition. Then
answer questions 3-12.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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3. Do you consider the patient’s condition to be temporary or non-chronic?
___ YES ___NO.
4. Was the patient admitted for an overnight stay in a hospital, hospice, or residential
medical care facility? ___NO ___ YES. If so, dates of admission _____________
5. Is the patient unable to perform one or more of the essential functions of his/her
position as a result of the condition? (Please refer to the job description provided on
page 1). ____YES ____NO.
6. If the answer to Question 5 is “YES,” please describe the essential function(s) the
patient is unable to perform.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
7. If the answer to Question 5 is “YES,” can you recommend any modifications or other
accommodations that would enable the patient to perform the affected essential
functions of the job? _____YES _____NO.
If applicable, please describe in detail the suggested job modification(s) or other
work accommodation(s) and the manner by which it would enable your patient to
perform the affected essential job functions including intermittent leave or reduced
schedule leave. If intermittent or reduced schedule leave is required, please
complete question 8.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
8. Based on the patient’s medical history and your knowledge of the medical condition,
estimate the frequency of flare-ups and the duration of incapacity for each. Please
circle the appropriate interval for each.
Planned: Frequency: _____times per ____week(s) month(s)
Duration: _____hours or_____day(s) per episode
Episodic (Unplanned): Frequency: _____times per ____week(s) month(s)
Duration: _____hours or_____day(s) per episode
Reduced Schedule: Cannot work more than ____hours/days per ___ day/week
9. Please provide the beginning and ending dates of any requested
intermittent/reduced schedule leave: Begin Date: _________ End Date: ________
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10. Does the patient need a continuous leave of absence because of his/her condition?
_____YES ___NO.
11. If the answer to Question 10 is “YES,” provide the dates for which the patient will
need to be off work (even if only your best estimate) and state whether you expect
the patient will be able to return to work. __________________________________
12. Additional Information:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
CERTIFICATION OF PHYSICIAN/HEALTH CARE PROVIDER
I hereby certify that all of the foregoing information is true and correct.
Signature of Provider: ________________________________________
Printed Name of Provider: _____________________________________
Date Signed: ________________________
Address of Provider: __________________________________________
__________________________________________
Telephone Number of Provider: _________________________
Licenses and Specialties of Provider: ______________________________
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Genetic Information Nondiscrimination Act (GINA) FMLA Certification
Disclosure
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and
other entities covered by GINA Title II from requesting or requiring genetic information
of an individual or family member of the individual, except as specifically allowed by this
law. To comply with this law, we are asking that you not provide any genetic
information when responding to this request for medical information. “Genetic
information,” as defined by GINA, includes an individual’s family medical history, the
results of an individual’s or family member’s genetic tests, the fact that an individual or
an individual’s family member sought or received genetic services, and genetic
information of a fetus carried by an individual’s family member or an embryo lawfully
held by an individual or family member receiving assistive reproductive services.
Please return this signed form with the completed “Certification of Health Care Provider”
Form.
Employee Signature: Date:
Health Care Provider Signature: Date:
