Medical Certification for EMPLOYEE FMLA - Form #1B - memphistn 2026

1. Click ‘Get Form’ to open it in the editor.
2. In Section 1, provide your name, division, job title, and contact information. Specify your regular work hours and check the appropriate box regarding authorization for your health care provider to share information.
3. Sign and date the form at the bottom of Section 1 to confirm your understanding of the implications of providing false information.
4. Section 2 is for the health care provider. Ensure they complete all parts accurately, including medical facts about your condition and any necessary treatment details.
5. The health care provider should also estimate the amount of leave needed in Part B, detailing any follow-up treatments or potential flare-ups that may affect your ability to work.

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