CONTACT INFORMATION

Authorization for Use or Disclosure of Protected Health Information

(Required by the Health Insurance Portability and Accountability Act --- 45 CFR Parts 160 and 164)

Your PHI will be release to:

Name: Brittany Walters
Employer: Nathson & Associates, FMLA/Leave Administrstor
Address; 145 Imperial Dr
Shaker Heights, Ohio 44120
Phone: 216-547-2612
E-mail: bwalters@nathson.com

Certification and Acknowledgement: I certify that I am the person (or the personal representative of the person) designated in Part 1. I agree that my individually identifiable health information described in Parts 3 and 4, and held by the person or entity listed in Part 2, may be disclosed to the person or entity listed in Part 5 for the purpose(s) designated in Part 6. I understand that, if the information to be disclosed is needed by a health care plan in order to determine my eligibility for plan benefits; or is needed by ABC Company to consider me for medical, sick or other leave; or to consider my eligibility or claim for short- or long-term disability or life insurance coverage or benefits, workers’ compensation benefits, or similar fringe benefits; or to consider me for employment or continued employment, my failure to provide this Authorization may prevent me from receiving the benefit or leave, or preclude me from being considered for employment or continued employment. I understand that I have the right to revoke this Authorization, in writing, at any time, by sending the revocation to the person or entity who received the Authorization, and that the revocation will be effective except to the extent that the person or entity releasing the information has already taken action in reliance on my Authorization. I understand that, once disclosed, it is possible that the health information may be further disclosed by the recipient and no longer subject to protection under international, federal, state, or local privacy rules. I have received a copy of my signed Authorization.

If this authorization is signed by a personal representative of the above-named patient, the personal representative must describe his or her authority to act:

Witnesses only need if ABC Company requests witnesses as required by law

This form is to be completed by the patient’s health care provider. FMLACERT@nathson.com

Information sought on this form relates only to the condition for which the employee is taking leave.

INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA/OFLA, 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 examination of the patient. Be as specific as you can; terms such as “lifetime,” “unknown,” or “indeterminate” may not be sufficient to determine FMLA/OFLA coverage. Limit your responses to the condition for which the employee is seeking leave.

EMPLOYEE LEAVE REQUEST:

Information sought on this form relates only to the condition for which the employee is taking leave.
 

Affirmative answer to the following question is not required for OFLA or concurrent OFLA/FMLA leave.

Affirmative answer to the following question is not required for OFLA or concurrent OFLA/FMLA leave.

Definition of a "Serious Health Condition":

A "serious health condition" is defined as an illness, impairment, physical or mental condition that involves one of the following:

Hospital care –Inpatient care (i.e., overnight stay) in a hospital, hospice, or residential medical care facility, including any period of incapacity or subsequent treatment in connection with or consequent to such inpatient care.

Absence plus treatment –A

period of incapacity of more than three consecutive calendar days (including any period of incapacity or subsequent treatment relating to the same condition), that also involves:

a. Treatments two or more times by a licensed healthcare provider, nurse, or physician's assistant under direct supervision of a healthcare provider, or by a provider of healthcare services (e.g., physical therapist) under orders of, or on referral by, a healthcare provider, or

b. Treatment by a healthcare provider on at least one occasion which results in a regimen of continuing treatment under supervision of the healthcare provider.

1. Treatment includes examinations to determine if a serious health condition exists and evaluations of the condition. Treatment DOES NOT include routine physical, dental, or eye examinations.

2. A regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic) or therapy requiring special equipment to resolve or alleviate the health condition. A regimen of treatment DOES NOT include the taking of over-the-counter medications such as aspirin, antihistamines, or salves; or bed-rest, drinking fluids, exercise, or any other similar activities that can be initiated without a visit to a healthcare provider.

Pregnancy –

Any period of incapacity due to pregnancy, pregnancy-related illness, or for prenatal care.

Chronic conditions requiring treatments –

A chronic serious health condition is one which:

a. Requires periodic visits for treatment by a healthcare provider, nurse, or physician's assistant under direct supervision of a healthcare provider;

b. Continues over an extended period of time (including recurring episodes of a single underlying condition); and

c. May cause episodic rather than continuing periods of incapacity (e.g., asthma, diabetes, epilepsy, etc.)

5. Permanent/ long-term conditions requiring supervision –

A period of incapacity that is permanent or long-term due to a condition for which treatment may not be effective. The employee or family member must be under the continuing supervision of, but need not be receiving active treatment by, a healthcare provider. Examples include Alzheimer's, a severe stroke or the terminal states of a disease.

6. Multiple treatments (non-chronic conditions) –

Any period of absence to receive multiple treatments (including any period of recovery therefrom) by a healthcare provider or by a provider of healthcare services under orders of, or on referral by, a healthcare provider, either of restorative surgery after an accident or other injury, or for a condition that would likely result in a period of incapacity of more than three consecutive calendar days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), kidney disease (dialysis).

Definition of "Incapacitated": Inability to work, attend school, or perform other regular daily activities due to the serious health condition, treatment therefore, or recovery therefrom.

Directions regarding “Regimen of treatment" (question 7): If the patient is under your supervision, provide a general description of such regimen, such as prescription drugs or physical therapy requiring special equipment. If the treatments will be provided by another provider of health services, such as a physical therapist, please state the nature of the treatments.

FAMILY AND MEDICAL LEAVE GUIDELINES

I understand that to be eligible for leave under the Family and Medical Leave Act, I must have been employed with the ABC Company for a cumulative total of 12 months AND have physically worked a minimum of 1,250 hours during the 12 months immediately preceding the beginning of the requested leave. If I do not meet eligibility, I understand that my request under FMLA will be denied. If my request for FMLA leave is approved, I understand that this period of leave will count toward the number of workweeks that I am entitled to under the Act. I understand that the 12 month period is a rolling 12 month period measured backward from the first date I use any FMLA leave. I also understand that under the rolling 12 month period, each time I take FMLA leave, the remaining entitlement is the balance of my unused workweeks. I understand that FMLA requests must be renewed or extended if the request and approved FMLA period has elapsed.

PARENTAL LEAVE GUIDELINES

I understand that under the provisions of Parental Leave from Company policy, I can take up to six months unpaid leave when I become the biological or adoptive parent of a child. I understand that Parental Leave may not begin more than two weeks prior to the expected date of the child’s arrival without supervisor and HR approval. I understand that Parental Leave may run concurrent with Family and Medical Leave entitlements. I understand that while on parental leave, I may request and be placed on annual leave with pay to cover any part of the six months period until all or any part of my earned annual leave has been used. I also understand that by completing the required medical certification, I may be allowed to use earned sick leave while on parental leave.

CERTIFICATION

I understand that the Family and Medical Leave/Parental Leave Health Care Certification or the Injured Service Member Health Care Provider Certification form is required at the time of my request for leave due to the serious health conditions of me or my child, spouse, or parent. In the case of placement of a child through adoption or foster care, I understand that appropriate documentation from the agency or jurisdiction placing the child is required. In order to take service-member family leave, I understand documentation from the appropriate branch of the Armed Forces is required referencing need for support of the contingency operation.

I, acknowledge that my FMLA request is not valid until it has been certified and approved by Human Resources. I also understand the requirement to communicate with my supervisor and Human Resources on an ongoing basis, if there are any changes in my leave request or return to work date.

PERIODIC COMMUNICATION
The employee will be required to contact their supervisor every day(s) of the status and intent to return to work. (Employees are required to follow all call in procedures for all absences.)

You are listed as the supervisor of an employee (see below) who has requested a leave of absence:

SECTION 1: EMPLOYEE INFORMATION

Contact information while on leave

Date Leave Resets

If applicable, please specify the person the leave is for and the relationship:

Research has shown that early return to work enhances both psychological and physical recovery while minimizing the negative impact of disability on an employee’s life. Nathson & Associates case managers will work with you, your department, and other university departments to identify opportunities to return to work as soon as it is reasonably safe for you to do so. We will also coordinate with the Return to Work Program as needed.

A return-to-work plan is developed—with assistance from Nathson & Associates—by you, your department, and your treatment team. Among other things, it includes information about any physical restrictions such as lifting or sitting for protracted periods of time along with a target date on which you will be fully recovered and able to assume your regular duties.

Nathson & Associates’ objective is to facilitate a safe and lasting return to work. Our staff will work with you, your department, and your physician to:

• Help evaluate essential functions of the job and anticipate needs for accommodations, if required.
• Discuss and develop a return-to-work plan.
• Maintain regular contact with you and your department to coordinate the return-to-work plan
• Follow up on medical progress and assist with any medical issues after you have returned to work
• EMPLOYEE: COMPLETE SECTION - A
• HEALTH CARE PROVIDER: COMPLETE SECTION - B
• MANAGER/SUPERVISOR OR HR REPRESENTATIVE: COMPLETE SECTION - C
  
  You must submit the completed form, to your agency human resources or supervisor, prior to your return to work or your return to work may be delayed or denied.

SUBMITTAL INSTRUCTIONS

• Submit at least 3 days prior to your return to work.
• Provide a copy to your Supervisor or HR Representative before starting to work.

PART 5: CERTIFICATION

I certify that the information provided in this form is true and correct to the best of my knowledge.

THE GENETIC INFORMATION NONDISCRIMINATION ACT OF 2008 (GINA): 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.