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- Click ‘Get Form’ to open it in the editor.
- Begin with Part I: Patient Information. Fill in your last name, first name, middle initial, and employee number along with the date.
- Move to Part II for Certification Relating to Your Own Serious Health Condition. Have your physician complete this section, specifying the estimated dates of absence and detailing the regimen of treatment prescribed.
- In this section, ensure that your physician indicates whether inpatient hospitalization is required and if you can perform work functions.
- If applicable, provide information regarding pregnancy by entering the estimated delivery date.
- Proceed to Part III for Certification Relating to Care for a Seriously Ill Family Member. Your physician will need to fill out details about your family member's condition and the necessity of your presence.
- Finally, complete Part IV: Authorization. Your physician must print their name, provide their phone number, sign, and indicate their field of specialization.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2004 | 4.8 Satisfied (62 Votes) |
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