PD Medical Certification PD 615A

HEALTH CARE PROVIDER CERTIFICATION
Family and Medical Leave

PD 615A
This form is used to provide certification per FMLA and OFLA regulations and law.
Section I: Employee Completes this Section

Employee’s name: _______________________________________________________
Patient’s name: _________________________________________________________
(Please check one) Relationship to patient:
self spouse parent child (age _____) domestic partner parent-in-law
grandparent grandchild parent of domestic partner child of a domestic partner (age ___)
Section II: Health Care Provider Completes this Section

Please complete all sections in order for the agency to determine Family and Medical leave entitlement.
Caution: Per the Genetic Information Nondiscrimination Act of 2008 (GINA) this agency is not requesting or requiring genetic
information* of its employees or their family members. In order for us to comply with this law, we ask that you not provide any genetic
information when responding to this request for medical information.
1. Please mark all that pertain to this patient (descriptions are on Page 2 of this certification):
A. Requires hospital care (hospice, residential care facility)
B. Requires absence from work plus treatment
C. Pregnancy disability or requires prenatal care
D. Chronic condition requiring treatment
E. Permanent or long-term condition requiring supervision
F. Requires multiple treatments for a non-chronic condition
G. None of the above
Describe the medical facts that support your above certification. ________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
2. Approximate date this condition began? _________________________________________________________

3. Probable duration of the patient’s present incapacity? (from)_________________(to)_____________________
4. Is this for either a chronic condition or for pregnancy? yes no If yes, is the patient presently incapacitated?
yes no If yes, what is the expected duration of the incapacity? _____________________________________
What is the expected frequency of the incapacity? ____________________________________________________
5. Will it be necessary for the employee to take time off intermittently or work on a reduced schedule due to the patient’s
condition or treatment? yes no If yes, what is the expected frequency for the absence?
______days per week, ______ days per month, reduce hours worked in a day to ______ for ______ days per week,
other (describe) __________________________________________________________________
6. Will the patient require a regimen of treatments? yes no If yes, describe the nature of the treatments, number of
treatments needed and the intervals between treatments _________________________________________________
_________________________________________________________________________________________________________________________________
7. If the patient is not the employee, will the patient need assistance for basic medical or personal needs, or safety or
transportation? yes no n/a patient is the employee If no, would the employee’s presence to provide psychological
comfort be beneficial or assist in the patient’s recovery? yes no
__________________________________________ ___________________________________________ ______________________
Signature of Health Care Provider Printed Name of Health Care Provider Date Signed
Field of practice _________________________Health care provider address: ______________________
Return this form to the patient or fax (marked CONFIDENTIAL) to the attention of Human Resources at
Fax # __________________ (Agency name)_________________________________________________
DEFINITIONS
This page defines the various serious health condition categories listed in section 1, A-G on the front of this certification and other
terms. A “serious health condition” is defined as an illness, impairment, physical or mental condition that involves one or more
of the following:
A. Hospital care: Inpatient care (i.e. overnight stay) in a hospital, hospice, or residential medical care facility, including any period
of incapacity or subsequent treatment in connection with or as a consequence of such inpatient care.
B. Absence plus treatment: A period of incapacity of more than three consecutive calendar days, including any subsequent
treatment or period of incapacity relating to the same condition, that also involves one or both of the following:
a. Treatment received in person, two or more times by a health care provider, a nurse, or a physician’s assistant under direct
supervision of a health care provider, or a provider of health care services (e.g., physical therapist) under orders of or referred
by a health care provider.
b. Treatment by a health care provider on at least one occasion resulting in a regimen of continuing treatment under the
supervision of the health care provider.
c. Regimen of Continuing Treatment: Includes a course of prescription medication such as an antibiotic or physical therapy
requiring special equipment to resolve or alleviate the health condition. A regimen of treatment does not include taking over-
the-counter medications such as aspirin, antihistamines or salves, bed-rest, drinking fluids, exercise, and other similar
activities that an individual can initiate without a visit to a health care provider.
C. Pregnancy or pregnancy disability: Any period of incapacity for pregnancy, pregnancy-related illness including severe morning
sickness, or for prenatal care or post pregnancy recovery.
D. Chronic conditions requiring treatments: A chronic serious health condition is one which:
a. Requires periodic in-person treatments by a healthcare provider, nurse, or physician’s assistant under direct supervision
of a healthcare provider.
b. Continues over an extended period of time, including recurring episodes of a single underlying condition.
c. May cause episodic rather than continuing periods of incapacity; for example, asthma, diabetes, epilepsy.
E. Permanent or long-term conditions requiring supervision: A period of incapacity that is permanent or long-term due to a
condition for which treatment is potentially ineffective. The employee or family member is under supervision of a health care
provider, not necessarily receiving active treatment. Examples are Alzheimer’s disease, a severe stroke, the terminal stages of a
disease.
F. Multiple treatments (non-chronic conditions): Any period of absence to receive multiple treatments (including any period of
recovery) by a health care provider or by a provider of health care services under orders of, or on referral by a health care provider
for restorative surgery after an accident or other injury, or for a condition that in the absence of treatment or medical intervention,
will likely result in a period of incapacity of more than three consecutive calendar days. For example: chemotherapy or radiation
for cancer, physical therapy for severe arthritis, dialysis for kidney disease.
G. None of the above: The patient does not have a serious health condition as described above.
Incapacity: The inability to work, attend school or perform other regular daily activities due to a serious health condition or
treatment for or recovery from a serious health condition.
*Genetic information: Information about: i) An individual's genetic tests; (ii) The genetic tests of that individual's family members;
(iii) The manifestation of disease or disorder in family members of the individual (family medical history); (iv) An individual's request
for, or receipt of, genetic services, or the participation in clinical research that includes genetic services by the individual or a family
member of the individual; or (v) The genetic information of a fetus carried by an individual or by a pregnant woman who is a family
member of the individual and the genetic information of any embryo legally held by the individual or family member using an assisted
reproductive technology.
2
Agency Form Number (optional) _________
DAS Healthcare Certification PD 615A (01-15-09)
Note: the agency may not alter this form except to add an agency form number, the name of the agency and the fax number.

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HEALTH CARE PROVIDER CERTIFICATION

Family and Medical Leave

Section I: Employee Completes this Section

Section II: Health Care Provider Completes this Section

2. Approximate date this condition began? _________________________________________________________

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