CIGNA Leave SolutionsSM

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CIGNA Leave Solutions Certification of Health Care Provider for Pregnancy Disability Leave /Employee s Serious Health Condition (Family and Medical Leave Act) ________________________________________ ________________________________________ ________________________________________ ________________________________________ ____________ Complies with DOL Form WH-380-E Revised January 2009 Date Prepared: Must Be Returned By: Employee Name: Employer Name: Leave ID: Reason for requesting Leave : Leave date(s)/Period(s) requested: SECTION I: For Completion by the EMPLOYEE INSTRUCTIONS to the EMPLOYEE: Please complete Section I before giving this form to your medical provider. The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA Leave due to your own serious health condition.

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 employees or their family members. In order to comply with this law, we are asking that …

  Information, Genetic, 2008, Nondiscrimination, Genetic information nondiscrimination act of 2008, Genetic information