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Certification of Health Care Provider for Family Members Serious Health Condition (Family and Medical Leave Act)U.S. Department of Labor Wage and Hour Division DO NOT SEND COMPLETED FORM TO THE DEPARTMENT
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What is member or hisher medical?
Member or his/her medical refers to the health information of an individual who is part of a healthcare plan or system.
Who is required to file member or hisher medical?
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Member or his/her medical information can be filled out by providing relevant health history, current conditions, treatments, and medications.
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The purpose of member or his/her medical is to ensure that healthcare providers have access to necessary health information to provide appropriate care and treatment.
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Information such as medical history, current health conditions, medications, allergies, and treatments must be reported on member or his/her medical.
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