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Patient Portal

Applying for FMLA leave

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.