Medical Certificate Form - Connecticut

State of Connecticut Human Resources
Medical Certificate
Return to:
Agency Name: _________________________________ Attn: Human Resources
Address:
______________________________________________________FAX:____________________
Must be submitted within 30 days of foreseeable leave , if leave is FMLA qualifying.
Form #: P33B – Caregiver To be used by employees seeking family leave to care for a spouse, child, or
Revision Date: 2/2011
parent with a “serious health condition/serious illness”.
AGENCY
INSTRUCTIONS
This medical c ertificate is to be used by employees seeking family leave to care for a spo use, child (under
age 18 or 18 or older a nd incapable of self-care because of mental or physical disability), or parent with a
“serious health condition” / “serious illness”. It shall be given to the employee or sent directly to the
physician or practitioner of the child, spous e or parent who needs care. T he name of the person and th e
address of the agency to which this certificate is to be retur ned shall be inserted in the space provided.
The PHYSICIAN OR PRACTITIONER will gener ally return the filled out certificate to the agency head or
authorized r epresentative. Fill in bel ow the employee’s name, position, and address, and the name of the
patient and his/her rel ationship to employee.
AGENCY FILL IN
Agency Head or Representative Agency Name
Agency Address (No. and Street)
(City or Town) (State) (ZIP Code)
Employee’s Name and Employee’s Number
Employee’s Position Department
Address (No. and Street)
(City or Town) (State) (ZIP Code)
Patient’s Name Relationship to Employee
CONDITIONS
GOVERNING
ISSUANCE
This form must
be executed by a
physician or
practitioner
whose me thod of
healing is
recognized by the
State, excep t
where other wise
indicated.
Note: The health
care provider
must practice in
the specialty for
which the patient
is being treated.
No federal FMLA, state family/medical leave (C.G.S. 5-248a), special leave with pay in excess of five (5) days,
or leave as otherwise prescribed b y contract, shall be granted state employees unless supported by a medical
certificate filed with, and acceptable to, the appointing authority. The period of employee absence must be
reported with a description of the nature of the patient’s incapacit y entered und er (2) and/or (7).
The Genetic Information N on discrimination Act of 2008 (GINA) prohibits employers and other entiti es covere d
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 informatio n when responding to this request for medical information. `Genetic inform ation'
as defined by GINA, includes an individual's family medical histor y, the results of an individual's or family
member's genetic tests, the fact that an individual or an individu al' s family member sought or received g enetic
services, and genetic i nformati on of a fetus carried by an individual or an i ndividual's family member or an
embryo lawfully held by an individual or family member receiving assistive reproductive services.
(1)
Pages 3-4 of this form describes what is meant by a “serious health condition” / “serious
illness” under federal FMLA and state family/medical leave (C.G.S. 5-248a). Does the patient’s
condition qualify u nder any of the categories described? (Please be sure to refer to pp. 3 and 4 for
specific definitions.) _________ If yes, please check the appropriate category:
(fill in “yes” or “ no”)
____ Inpatient care with overnight stay ____ Permanent/long-term conditi ons requiring supervision
____ Incapacity and treatment ____ Multiple treatments (non-chronic con ditio ns)
____ Pregnancy (includes pre natal) ____ None of the above
____ Chronic conditions requiring treatments
(2) If this is for an FMLA qualifying reason, describe the medical facts that support your certification,
including a brief statement as to how the medical facts meet the criteria of one of the categories on
pages 3-4. If this is not for an FM LA qualifying reason, des cribe the medical facts that support your
certification of the patient’s me dical condition. If additio nal space is needed, continue remarks under
Section (7).
_____________________________________________________________________________
_____________________________________________________________________________
____________________________________________________________________________
1
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