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FMLA LEAVE REQUEST FORM (The following request is to be completed and returned to the Human Resource Office) EMPLOYEE REQUEST Employee s Name Employee s Department Date Request for Full-Time Leave

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Our HR hotline Christi's countless questions throughout the year regarding which medical professionals can fill out FMLA forms for employees which is what we will be discussing in a few moments but first a little background regarding the FMLA process in order to be placed on a Family Medical Leave a health care provider must complete a certification form in order to ensure the validity of the serious health condition the FMLA regulations specifically define the term health care provider as a doctor of medicine or Osteopathy who is authorized to practice medicine or any other person determined by the Secretary of Labor to be capable of providing health care services the other persons capable of providing health care services must be authorized to practice in their state and authorized to diagnose and treat physical or mental health conditions examples include providers such as podiatrists dentists clinical psychologists optometrists chiropractors nurse practitioners midwives clinical social workers' physician assistants and certain Christian Science practitioners, although this is not an exhaustive list it is important to remember that non-traditional providers may still meet the definition outlined by FMLA regulations if you are questioning a medical professionals' authorization to flout the FMLA form it is always best to check the published FMLA regulations or members of the management Association may always contact the HR hotline for assistance you

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