What email address or phone number would you like to use to sign in to Docs.com?
If you already have an account that you use with Office or other Microsoft services, enter it here.
Or sign in with:
Signing in allows you to download and like content, and it provides the authors analytical data about your interactions with their content.
Embed code for: 1=Certifciation for Self (Leave) (5)
Select a size
Certification of healthcare provider for associate’s serious health condition
Associate name: Associate WIN:
Instructions to the associate: Please give 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. Your response is required to obtain or retain the benefit of FMLA protections. Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA request. Your employer must give you at least 15 calendar days to return this form. It is your responsibility to ensure that the certification is provided in a timely manner. Return the completed form by email, fax or upload to viaOne® express (as shown above), or send through the mail to: Walmart Disability and Leave Service Center at Sedgwick, PO Box 14028, Lexington, KY, 40512. (Please keep a copy for your records.)
Instructions to the healthcare 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 the condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Be as specific as you can; terms such as “lifetime,” “unknown,” or “indeterminate” may not be sufficient to determine FMLA coverage. Limit your responses to the condition for which the associate is seeking leave. Please be sure to sign the form on the last page.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. "Genetic Information" as defined by GINA includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
Provider’s name: ____________________________________________________________________________
Business address: ____________________________________________________________________________
Type of practice / Medical specialty: ____________________________________________________________
Telephone: _________________________________ Fax:___________________________________________
MED 1 OF 3
Associate name: Associate WIN:
PART A: MEDICAL FACTS
Approximate date condition commenced:____________________________________________________
Probable duration of condition: ____________________________________________________________
Mark below as applicable:
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
___No ___Yes If so, dates of admission: Date admitted:_____________ Date released:______________
Date(s) you treated the patient for condition (including scheduled follow up appointments or procedures):
Will the patient need to have treatment visits at least twice per year due to the condition? ___No ___ Yes
Was medication, other than over-the-counter medication, prescribed? ___No ___Yes
Was the patient referred to any other healthcare provider(s) for evaluation or treatment (e.g., physical therapist)? ____No ____Yes
If so, state the nature of such treatments and expected duration of treatment:
Is the medical condition pregnancy? ___No ___Yes If so, expected delivery date: ___________________
For the following question, use the job information provided by the employer. If the employer fails to provide a list of the associate’s essential functions or a job description, answer these questions based upon the associate’s own description of his/her job functions.
Is the associate unable to perform any of his/her job functions due to the condition: ____ No ____ Yes
If so, identify the job functions the associate is unable to perform:
Describe other relevant medical facts, if any, related to the condition for which the associate seeks leave (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):
NOTE: In California, Connecticut and Wisconsin, do not disclose the underlying diagnosis unless you have received consent from the patient.
MED 2 OF 3
PART B: AMOUNT OF LEAVE NEEDED
Will the associate be required to be away from work for a single continuous period of time due to his/her medical condition, including any time for treatment and recovery? ___No ___Yes
If so, provide an estimate of the continuous dates the associate will be away from work: Start date:______________ End date:______________
Will the associate need to attend follow-up treatment appointments because of the associate’s medical condition? ___No ___Yes
If so, are the treatments medically necessary? ___No ___Yes
Estimate the treatment schedule, if any. Include the dates of any scheduled appointments and the time required for each appointment, including any travel time and any recovery period. Please provide a numerical response – For example: 1 appointment every 3 months, and requires 1 day of recovery per appointment:
Frequency: _____ appointment(s) every _____ week(s) or _____ month(s)
Duration: _____ hours or ___ day(s) per appointment
7. Will the condition cause episodic flare-ups periodically preventing the associate from performing his/her job functions? ____No ____Yes
Is it medically necessary for the associate to be absent from work during the flare-ups? ____No ____ Yes
If so, explain:
Based upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of flare-ups and the duration of time the patient may need to be away over the next 6 months. Please provide a numerical response – For example: 1 episode every 3 months lasting 1-2 days:
Frequency: _____ times per _____ week(s) or _____ month(s)
Duration: _____ hours or ___ day(s) per episode
Will the associate need to work part-time or on a reduced schedule because of the associate’s medical condition? ___No ___Yes
If so, is the reduced number of hours of work medically necessary? ___No ___Yes
Estimate the part-time or reduced work schedule the associate needs, if any:
__________ hour(s) per day; __________ days per week from _____________ through _____________
ADDITIONAL INFORMATION: Please reference the question number for any related information you provide
Signature of healthcare provider Date
MED 3 OF 3
Return all documents to Sedgwick in one of three ways:
upload: viaOne® express | email: WalmartForms@sedgwicksir.com | fax: 859-264-4372 or 859-280-3270
COMPLETE YOUR FORMS | MEDICAL INFORMATION
HCPC 1200of such treatments and expected duration of treatment: