Transcription of Department of Citywide Administrative Services ...
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Department of Citywide Administrative Services ...
The City of New YorkDepartment of Citywide Administrative ServicesCERTIFICATION OF PHYSICIAN OR OTHER health care PROVIDER under the Family and Medical Leave s s Name (if different from employee) attached sheet describes what is meant by a serious health condition under the Family and Medical LeaveAct. Does the patient s condition1 qualify under any of the categories described? If so, please check the applicablecategory.(1) ____ (2) ____ (3) ____ (4) ____ (5) ____ (6) ____, or None of the above the medical facts which support your certification, including a brief statement as to how the medical factsmeet the criteria of one of these the approximate date the condition commenced, and the probable duration of the condition (and also theprobable duration of the patient s present incapacity2 if different)
A “Serious Health Condition” means an illness, injury impairment, or physical or mental condition that involves one of the following: 1. Hospital Care Inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical care facility, including any period of incapacity2 or subsequent treatment in connection with or consequent to such inpatient care.
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