Fillable Printable Medical Certificate Form - Connecticut

Medical Certificate Form - Connecticut

State of Connecticut Human Resources

Medical Certificate

Return to:

Agency Name: _________________________________ Attn: Human Resources

Address:

______________________________________________________FAX:____________________

Must be submitted within 30 days of foreseeable leave , if leave is FMLA qualifying.

Form #: P33B – Caregiver To be used by employees seeking family leave to care for a spouse, child, or

Revision Date: 2/2011

parent with a “serious health condition/serious illness”.

AGENCY

INSTRUCTIONS

This medical c ertificate is to be used by employees seeking family leave to care for a spo use, child (under

age 18 or 18 or older a nd incapable of self-care because of mental or physical disability), or parent with a

“serious health condition” / “serious illness”. It shall be given to the employee or sent directly to the

physician or practitioner of the child, spous e or parent who needs care. T he name of the person and th e

address of the agency to which this certificate is to be retur ned shall be inserted in the space provided.

The PHYSICIAN OR PRACTITIONER will gener ally return the filled out certificate to the agency head or

authorized r epresentative. Fill in bel ow the employee’s name, position, and address, and the name of the

patient and his/her rel ationship to employee.

AGENCY FILL IN

Agency Head or Representative Agency Name

Agency Address (No. and Street)

(City or Town) (State) (ZIP Code)

Employee’s Name and Employee’s Number

Employee’s Position Department

Address (No. and Street)

(City or Town) (State) (ZIP Code)

Patient’s Name Relationship to Employee

CONDITIONS

GOVERNING

ISSUANCE

This form must

be executed by a

physician or

practitioner

whose me thod of

healing is

recognized by the

State, excep t

where other wise

indicated.

Note: The health

care provider

must practice in

the specialty for

which the patient

is being treated.

No federal FMLA, state family/medical leave (C.G.S. 5-248a), special leave with pay in excess of five (5) days,

or leave as otherwise prescribed b y contract, shall be granted state employees unless supported by a medical

certificate filed with, and acceptable to, the appointing authority. The period of employee absence must be

reported with a description of the nature of the patient’s incapacit y entered und er (2) and/or (7).

The Genetic Information N on discrimination Act of 2008 (GINA) prohibits employers and other entiti es covere d

by GINA Title II from requesting or requiring genetic information of an individual or family member of the

individual, except as specifically allowed by this law. To comply with this law, we are asking that you not

provide any genetic informatio n when responding to this request for medical information. `Genetic inform ation'

as defined by GINA, includes an individual's family medical histor y, the results of an individual's or family

member's genetic tests, the fact that an individual or an individu al' s family member sought or received g enetic

services, and genetic i nformati on of a fetus carried by an individual or an i ndividual's family member or an

embryo lawfully held by an individual or family member receiving assistive reproductive services.

(1)

Pages 3-4 of this form describes what is meant by a “serious health condition” / “serious

illness” under federal FMLA and state family/medical leave (C.G.S. 5-248a). Does the patient’s

condition qualify u nder any of the categories described? (Please be sure to refer to pp. 3 and 4 for

specific definitions.) _________ If yes, please check the appropriate category:

(fill in “yes” or “ no”)

____ Inpatient care with overnight stay ____ Permanent/long-term conditi ons requiring supervision

____ Incapacity and treatment ____ Multiple treatments (non-chronic con ditio ns)

____ Pregnancy (includes pre natal) ____ None of the above

____ Chronic conditions requiring treatments

(2) If this is for an FMLA qualifying reason, describe the medical facts that support your certification,

including a brief statement as to how the medical facts meet the criteria of one of the categories on

pages 3-4. If this is not for an FM LA qualifying reason, des cribe the medical facts that support your

certification of the patient’s me dical condition. If additio nal space is needed, continue remarks under

Section (7).

_____________________________________________________________________________

____________________________________________________________________________

(3) (a) Answer the following:

1. The approximate date the condition commenc ed. ______________________________

2. The probable duration of the condition. _____________________________________

3. The probable duration of the patie nt’s present incapacity (if different from (3)(a) 2. above).

_____________________________________________________________________________________

4. The date of the patient’s most recent examination for the condition. ________________

(b) If condition is a “chronic condition” (as checked off under Section (1)), state whether the

patient is presently incapacitated and the likel y duration and freque ncy of episodes of incapacit y:

_____Patient ____ is ____ is not pr esently incapacitated. (check one)

Going forward, estimate the:

____Duration of episodes of i ncap acity = _______________ (hours or d ays, etc.)

____Frequency of episodes of incapacity = ____ _________ (no. of times per week or month, etc.)

TO BE FILLED IN

BY ATTENDING

PHYSICIAN OR

PRACTITIONER

(Please print legibly.)

(4)

(a) If additional treatments will be required for the conditio n, provide:

____ An estimate of the probable number of such treatments. ______________________

____ An estimate of the probable inter val between such treatments. _________________

____ An actual or estimated dates of treatment, if known. __________________________

____ Period re quired for recovery, if any. _______________________________________

(b) If any of these treatments will be provided by another pro vider of h ealth services (e.g.,

physical therapist), please state the nature of the treatment and period of time covered.

_________________________________________________________________________

provide a gene ral description of such regiment (e.g., prescription drugs, physical therapy

requiring special equipment). _________________________________________________

_________________________________________________________________________

(5)

(a) Does the patient require assistance for basic medical or personal needs or safety, or for

transportation?

(fill in “yes” or “no”)

(b) If no, would the employee’s presence to provide psychological comfort be beneficial to th e

patient or assist in the patient’s recovery?

(fill in “yes” or

“no”)

probable duration and frequ ency of this need.

_________________________________________________________________________

(6)

The caregiver/employee will be able to retur n to work on _____________ _____ (date).

(7)

Additional remarks:

Name of Physician or Practitioner AND Physician or Practitioner License Number (please type or print)

Address (No. and Street)

(City or Town) (State) (ZIP Code)

Signed (Physician or Practitioner) Date Telephone

FEDERAL FMLA:

Under the federal FMLA, “Serious Health Condition” is defined as an illness, injury, impairment, or physical or mental

condition that involves:

 Any period of incap acity or treatment related to inpatient care

(i.e., an overnight stay in a hospital, hospice,

residential facility, OR

 Continuing treatment by a health care provider.

“Continuing treatmen t” b y a health care provider includes any one or more of the following:

1) Incapacity and Treatment:

: A period of incapacity of more than three consecutive full calen dar days and

any subsequent treatment or period of incapacity relating to the same condition, that also involves:

 Treatment two or more times within 30 days of the first day of incapacity, unless extenuating

circumstances exist, , OR

 Treatment by a health care provider on at least one occasion which results in a regimen of

continuing treatment unde r the supervision of the heal th care provider.

Treatment means an in-person visit to a health care provider. The first (or only) in-person treatment

visit

must take place within seven (7) days of the first day of incapacity.

2) Pregnancy

: Any period of incapacity due to pregnancy, or for prenatal care.

3) Chronic Co nditions Requiring Treatments

: Any period of incapacity or treatment for such incapacity due

to a chronic condition which:

 Requires periodic visits for treatment by a health care provider or by a nurse physician’s assist ant

under direct supervision of health care provider;

 Continues over an extended period of time (including recurring episodes of a single underlying

condition); AND

 May cause episodic rather than a continuing period of incapacity. Examples

: asthma, diabetes,

epilepsy.

4) Permanent/Long-term Conditions

: A period of incapacity, which is permanent or long-term due to a

condition for which treatment may not be effective. The employee or family member must be under the

continuing supervision of, but need not be receiving active treatment by, a health care provider.

Examples

: Alzheimer’s, a severe stroke, or the terminal stages of a disease.

5) Multiple Treatments (Non-Chronic Conditions)

: Any period of absence to receive multiple treatments

(including any period of recovery therefrom) by a health care provider or by a provider of health care

services under orders of, or on referral by, a health care provider, either for restorative surgery after an

accident or other injury, or for a condition that would likely result in a period of in capacity of more than

three consecutive calendar days in the absence of medical intervention or treatment. Examples

: cancer

(chemotherapy, radiation, etc.) severe arthritis (ph ysical therapy), and kidney disease (dialysis).

Note:

Substance abuse may be a serious health condition if the conditions mentioned above are met. However, FMLA leave may only be taken for

treatment for sub stance abuse by a health care provider or by a provider of health care services on referral by a health care provider. On the other

hand, absence because of the employee’s use of the substance, rather than for treatment, does not qualify for FMLA leave.

Please Note : For the purposes of federal FMLA the following terms are defined to mea n:

 “Incapacity” – inability to work, attend school or pe rform other regular daily activities due to the serious health condition, treatment therefore,

or recovery therefrom.

 “Treatment” – includes examinations to determine if a serious health condition exists and evaluations of the condition. It does not include

routine physical examinations, eye examinations, or dental examin ations.

 A “regimen of continuing treatment” – includes, for example, a course of prescription medication (e.g. an antibiotic) or therapy requiring

special equipment to resolve or alleviate the health condition. It does not include the taking of over-the-counter medications such as aspirin,

antihistamines, or salves, or bed-rest, drinking fluids, exercise, and other similar activities that can be initiated without a visit to a health care

provider.

 “Intermittent Leave” – is leave taken in separate blocks of time due to a single qualifying reason.

 “Reduced Leave Schedule” – is leave schedule that reduces an employee’s usual number of working hours per work-week or hours per

workday. It is a change in the employee’s schedule for a period of time, normally from full-time to part-time.

STATE FAMILY / MEDICAL LEAVE (C.G.S. 5-248a):

Under the state’s family/medical leave law, “Serious Illness” is defined as an illness, injury, impairment or

physical or mental condition that involves:

 Inpatient care in a hospital, hospice, or residential care facility;

 Continuing treatment or continuing supervision by a health care provider [C.G.S. 5-248a(c) and CT

State Regulation 5-248b-1(d)].