Certification of Health Care Provider for Employee s ...

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DOL-FME (rev. 12/21). CTFMLA CT Department of Labor Employee Name: ________________________________________ __________________. Certification of Health Care Provider for Employee 's Serious Health Condition DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR. RETURN TO THE PATIENT. The Connecticut Family and medical Leave Act (CTFMLA) provides that an employer may require an Employee seeking CTFMLA protections for leave due to a serious Health condition to submit a medical Certification issued by the Employee 's Health care Provider .

(1) Due to the condition, the patient (☐ had / ☐ will have) planned medical treatment(s) (scheduled medical visits) (e.g. psychotherapy, prenatal appointments) on the following date(s): (2) Due to the condition, the patient (☐ was / ☐ will be) referred to other health care provider(s) for evaluation or treatment(s).

  Health, Medical, Appointment