Page 1 Form WH-380-E Revised May 2015 Certification of Health Care Provider for U.S. Department of Labor Wage and Hour Division(Family and Medical Leave Act) DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT OMB Control Number: 1235-0003 Expires: /3/20 SECTION I: For Completion by the EMPLOYER INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because of a need for leave due to a serious health condition to submit a . Please complete Section I before giving this form to your employee. Your response is voluntary. While you are not required to use this form, you may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. 247247 825.306-825.308. Employers must generally maintain records and documents relating to medical certifications, recertifications, or medical histories of employees created for FMLA purposes as confidential medical records in separate files/records from the usual personnel files and in accordance with 29 C.F.R. 247 1630.14(c)(1), if the Americans with Disabilities Act applies, and in accordance with 29 C.F.R. 247 1635.9, if the Genetic Information Nondiscrimination Act applies. Employer name and contact: Check if job description is attached: SECTION II: For Completion by the EMPLOYEE INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your medical provider. The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to your own serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections. 29 U.S.C. 247247 2613, 2614(c)(3). Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA request. 2 C.F.R. 247 825.313. Youremployer must give you at least 15 calendar days to return this form. 29 C.F.R. 247 825.305(b). Your name: First Middle Last SECTION III: For Completion by the HEALTH CARE PROVIDER INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA. Answer, fully and completely, all applicable parts. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and be sufficient to determine FMLA coverage. Limit your responses to the condition for which the employee is seeking leave. Do not provide information about genetic tests, as defined in 29 C.F.R. 247 1635.3(f), genetic services, as defined in 29 C.F.R. 247 1635.3(e), or the manifestation of disease or disorder in family members, 29 C.F.R. 247 1635.3(b). Please be sure to sign the form on the last page. Type of practice / Medical specialty: Telephone: () Fax:() American LegalNet, Inc. www.FormsWorkFlow.com Mark below as applicable: 003 003 American LegalNet, Inc. www.FormsWorkFlow.com 002Is it medically necessary for the employee to be absent from work during the flare-ups? No Yes. If so, explain: American LegalNet, Inc. www.FormsWorkFlow.com Signature of Health Care Provider Date PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT. American LegalNet, Inc. www.FormsWorkFlow.com