Forms Instructions for CalHR 755 Medical Certification of Health Care Provider

Certification of Health Care Provider for Family Member's Serious Health Condition CalHR 755

Like the FMLA, the California Family Rights Act states that an employer can request a medical validation form to verify that a qualifying employee can take an unpaid leave of absence to care for and ailing parent, child or spouse.

The state and federal leave laws are quite similar in a number of ways, but they do have a few key differences.

As they relate to leave for family members, the FMLA allows for employers to ask for a diagnosis of a covered family member; however, the California law expressly prohibits this practice.

The employee requesting leave under the CFRA is said to have sufficient information if they provide the date the injury happened or illness began, expected duration of the debilitating condition, expected length of time a family member will need care and a statement from a provider or other official on the legitimacy of the need for CFRA leave.

With respect to leave for a birth, adoption or placement of a child – the two laws are similar, with the exception that an employee is not mandated to provide validation when asking for leave to adopt a child.

Form Instructions

Certification of Health Care Provider for Family Member's Serious Health Condition (CalHR 755)
Part A: To be completed by the employee

The employee requesting leave should complete Part A before giving the form to either their qualifying family member or that family member’s healthcare provider. If the employee does not properly complete Part A and return the entire completed form within 15 calendar days, the request may not be valid or protected under the FMLA or the CFRA.

For Part A, the employee needs to provide their full name, telephone number, job classification, job department, last day worked, work schedule and ailing person’s relation to the employee. If that person is the employee’s child, the child’s date of birth needs to be given.

The employee also needs to describe the care they will be providing to their family member and the amount of time that care is expected to last.

Certification of Health Care Provider for Family Member's Serious Health Condition (CalHR 755)
Part B: To be completed by the relevant healthcare provider

In Part B and all subsequent parts of the form, the family member’s healthcare provider needs to provide their information along with their best estimate of the duration and frequency of care that the employee will be providing to their patient. The healthcare provider should not disclose the underlying nature of their patient’s condition.
The provider first needs to give their name, business address, type of practice, telephone number and fax number.

Certification of Health Care Provider for Family Member's Serious Health Condition (CalHR 755)
Part C: To be completed by the relevant healthcare provider

In Part C, the provider needs to state if their patient has a ‘serious health condition’ as described at the bottom of the form. If the patient does have a ‘serious health condition,’ the provider then needs to give the approximate date that it started, treatment dates and possible duration of the condition.
The provider also needs to state if the patient will need treatment at least twice per year, require prescription medication and if the employee needs to participate as a part of the treatment regimen.

Certification of Health Care Provider for Family Member's Serious Health Condition (CalHR 755)
Part D: To be completed by the relevant healthcare provider

In Part D, the provider needs to state if the patient was remanded to another provider for treatment. If a treatment specialist is involved, the provider should give the duration and frequency of those treatments.

The provider also needs to state whether or not the patient will be incapacitated for any length of time, and if so give the dates for the period of incapacitation. The provider then needs to say if there will be follow-up treatments, and if so give an estimated schedule.

Finally, the provider needs to give details about their patient’s condition as it relates to the employee missed time from work. The provider must state if the employee may need time off on an intermittent basis, and if so give the expected days or hours they might miss. The provider also needs to say if there will be occasional flare-ups and the frequency of any flare-ups.

The bottom of Part D also provides a space where a provider may provide any additional information that could be relevant to the employee’s FMLA leave request.

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