Transcription of Certification of Health Care Provider for Family Member’s ...
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Certification of Health care Provider for Department of Labor Family Member's serious Health Condition Wage and Hour Division ( Family and Medical Leave Act). _____. DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT. OMB Control Number: 1235-0003. Expires: 8/31/2018. SECTION I: For Completion by the EMPLOYER. INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because of a need for leave to care for a covered Family member with a serious Health condition to submit a medical Certification issued by the Health care Provider of the covered Family member. Please complete Section I before giving this form to your employee.
Certification of Health Care Provider for . U.S. Department of Labor. Family Member’s Serious Health Condition (Family and Medical Leave Act) Wage and Hour Division
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CERTIFICATION OF FAMILY MEMBER’S SERIOUS HEALTH, Family, Health, Certification, Serious, Family member, Or Dependent Care Leave, Member, CERTIFICATION OF EMPLOYEE'S SERIOUS HEALTH, Certification of Health Care Provider, S Serious Health, TO RETURN FROM LEAVE CERTIFICATION, Department of Citywide Administrative Services, Department of Citywide Administrative Services CERTIFICATION OF PHYSICIAN, Peer Support Programs in Children’s, Dear Employee, 20-1923 01-09