- Complete the “Family or Medical Leave Request Form” and return to Human Resources (hinsonc@mphci.com). This form does not require completion by a medical provider but must accompany all requests for FMLA leave.
- If the leave request is for your own serious health condition, print the “Certification of Health Care Provider for Employee’s Serious Health Condition (Family and Medical Leave Act)”.
- As the employee, you are responsible for completing Section II.
- This form does require completion by your medical provider – they must fully complete and sign Section III before it is returned to Human Resources for processing
- Employees have 15 days to return the completed forms to HR for processing.
- If the leave request is for a family member’s serious health condition, print the “Certification of Health Care Provider for Family Member’s Serious Health Condition (Family and Medical Leave Act)”.
- As the employee, you are responsible for completing Section II.
- This form does require completion by your medical provider – they must fully complete and sign Section III before it is returned to Human Resources for processing
- Employees have 15 days to return the completed forms to HR for processing.
- If the leave request is for qualifying exigency for military family leave, print the “Certification of Qualifying Exigency For Military Family Leave (Family and Medical Leave Act)”.
- As the employee, you are responsible for completing Section II. Written documentation confirming duty dates is required
- This form does not require completion by your medical provider.
- Employees have 15 days to return the completed forms to HR for processing.
- If the leave request is for the serious injury or illness of a current service member, print the “Certification for Serious Injury or Illness of a Current Service Member – for Military Family Leave (Family and Medical Leave Act)”.
- As the employee, you are responsible for completing Section I.
- This form does require completion by a United States Department of Defense Health Care Provider or a Health Care provider as defined in 29 CFR 825.125.
- Employees have 15 days to return the completed forms to HR for processing.
- If the leave request is for the serious injury or illness of a Veteran, print the “Certification for Serious Injury or Illness of a Veteran – for Military Family Leave (Family and Medical Leave Act)”.
- As the employee, you are responsible for completing Section I.
- This form does require completion by your medical provider – they must fully complete and sign Section III before it is returned to Human Resources for processing
- Employees have 15 days to return the completed forms to HR for processing.
