Health Care Provider Certification Approval Template | CMP103-1

Health Care Provider Certification Approval Template

Employees must submit a Health Care Provider Certification Approval Template to support a request for leave because of a serious health condition. CMP103-1 CERTIFICATION OF HEALTH CARE PROVIDER is to be filled out with medical facts, a date the condition commenced, changes to the work schedule, and more. Two or three opinions (at employers expense) may be required as well as a fitness for duty report to return to work. Employees should have at least 15 calendar days to obtain the medical certification.

Keep in mind unpaid leave will be granted for any of the following reasons:

• To care for the employee’s child after birth, or placement for adoption or foster care.
• To care for the employee’s spouse, son or daughter, or parent, who has a serious health condition.
• For a serious health condition that makes the employee unable to perform the employees job.

Health Care Provider Certification Approval Template Details

Pages: 05
Words: 1158
Format: Microsoft Word 2013 (.docx)
Language: English
Manual: Human Resources
Category: Compliance
Procedure: Family Medical Leave Procedure FMLA CMP103
Type: Form

Related Documents

• CMP103-2 EMPLOYER RESPONSE TO REQUEST FOR LEAVE