Transcription of Certification of Employee Health Care Provider
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Certification of Employee Health Care Provider
NYL GBS Leave Solutions Box 29050 Phoenix, AZ 85038-9050 Fax: Phone: Document ID: 158210107 Notification #: _____ Absence #: _____ Page 1 of 3 NYL GBS Leave Solutions Certification of Health Care Provider for Employee s Serious Health Condition Date Prepared: _____ Must Be Returned By: _____ Employee Name: _____ Employer Name: _____ Notification #: _____ 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 Genetic Information Nondiscrimination Act of 2008 (GINA), and, where applicable, the California Genetic Information Nondiscrimination Act of 2011 (CalGINA), prohibits employers and other entities covered by GINA Title II, and where applicable CaGl INA, from requesting or requiring genetic information of employees or their
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