Forms Instruction: Certification of Health Care Provider for Employee’s Serious Health Condition (CalHR 754)

The California Family Rights Act (CFRA) is very similar to its federal counterpart – the Family and Medical Leave Act (FMLA) – in many ways, including the stipulation that says an employer can require a valid medical certification for an employee requesting leave.

However, there are a few differences between the two laws when it comes to medical certification.

The FMLA states that an employer may ask for a medical diagnosis of an employee’s serious health condition on a medical validation form. The California leave law expressly prohibits employers from making such requests.

Click Here to View or Download FMLA Forms: Certification of Health Care Provider for Employee’s Serious Health Condition (CalHR 754)

The employee requesting leave under the CFRA is said to provide sufficient information if they have given the start date of the condition, expected duration of the condition and a statement from a provider or other official on the validity of the need for CFRA leave.

Form Instructions

Certification of Health Care Provider for Employee’s Serious Health Condition (CalHR 754)
Part A: To be completed by the leave administrator

Part A needs to be completed before the form is given to the employee. This section of the form asks for the requesting employee’s basic information, including his or her full name, job classification, work unit, department contact and that contact’s phone number. The administrator should also attach a copy of the employee’s job description and essential duties to the form.

Certification of Health Care Provider for Employee’s Serious Health Condition (CalHR 754)
Part B: To be completed by the requesting employee

The employee has to complete the next part of the form before giving it to their healthcare provider for the next section. An employee must submit a timely, completed and appropriate medical certification in order for the request to be valid and protected under the CFRA and FMLA laws. For this specific section, the employee only needs to provide their daytime phone number and details of their work schedule.

Certification of Health Care Provider for Employee’s Serious Health Condition (CalHR 754)
Part C: To be completed by the employee’s healthcare provider

In this and all subsequent sections of the CFRA form, a health care provider must fully and properly answer all parts for a request to be protected and valid. For Part C, the provider only needs to supply their name, address, type of practice and contact information.

Certification of Health Care Provider for Employee’s Serious Health Condition (CalHR 754)
Part D: To be completed by the employee’s healthcare provider

Next, the provider needs to verify that the employee does have a ‘serious health condition,’ meaning they are incapacitated, have been admitted to a hospital, are about to undergo surgery or are recovering from a serious medical treatment.

The provider then has to give the approximate date that the condition or treatment started, and the dates that treatment was given. The provider also has to say if the employee was referred to a specialist for either evaluation or treatment. If the employee is going through a treatment regimen, the dates of that regimen need to be given.

The provider also has to say if the employee can perform the job duties as described in the leave administrator’s attachment. If there are duties that an employee will not be able to perform, the provider should list those duties.

Finally, the provider should state if an employee can return under light or modified duty. If so, the provider should describe both the type of modified duty and expected duration that the change will be needed.

Certification of Health Care Provider for Employee’s Serious Health Condition (CalHR 754)
Part E: To be completed by the employee’s healthcare provider

The final part of the form is necessary to describe the amount of time required to change the employee’s status. The provider first needs to state whether the employee will be out for a single block of time and the length of that block. The provider also needs to describe any follow-up appointments that may be needed, including an expected treatment schedule.

If an employee will need to work a reduced schedule, the provider should state that and give the type of schedule that the employee should be confined to as a result of their situation. A reduced schedule might include only working a few hours a day or a few days per week.

Finally, the provider should say if the employee’s medical condition will cause any episodic flare-ups. If flare-ups are expected, the provider should estimate the frequency of the flare-ups and expected duration of each one.

Part E also provides a large space when the provider can attach any additional notes or information.

 

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