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su~~F:c~r: FA.MZ.LY Mr:c~~r_AI, Isr;AV~ AcT tF) PAGL, z r . ~z <br />PAGE 1G QF 19 <br />DPSr_ribe car°e you will provides to yaur family mernbr~r and estimate <br />leave; neaded to provide care: <br />Signatux'e <br />Late <br />SECTION III: For completion by the HEALTH CARE PROVIDER - INSTRUCTIONS <br />to the HEALTH CARE PROVIDER: ThN emplayce liste/ci above has .rc%queste~l <br />leave under the FMLA to carp for- yaur patient. Answer, fully anti <br />completely, all applicable parts belaw. 5ever.a7. tZuesti.arrs seek ,r <br />response as to the frequency or duratiort of a condition, treatment, <br />etc. Your answer should be yaux' best. nstimatc~ ba~rrd upon your medzca! <br />kr'rowledge, expex°ience, and e=xamir:atian of the patient. Be as spe=cifi: <br />F~5 ynLl CdI"); tex'ms SUC.~I aS ~lifetmr'," "UnknOWl'1," ar ".lCtdeterml,r7ate" <br />may rrot be strfficient Lo deter°mine PMLA coverage. Limit your <br />re:~pr:,nsc}s to they condition Ear which th~~ pat.i.rrnt needs leave. [}age ~i <br />pravides spare far addi.t:ional nfarmation, shotald you need. it. E~lease <br />be sure to s i grr the farrtr on the last page . <br />E'~rovitier's narrre~ and business address: <br />Type of prartic:eJMedi.cal specialty: <br />Te].ephcne:( ) Fax: t ) <br />PART' A : MIDI CAL F'ACT'S <br />1 . xapproxiina'~e date condition camntcinced: <br />Probable ciu:rat ic7n of conch t ion <br />wa.s the patient admitted for' an overnic3Ytt stay ira a hospital, <br />t-~c~spi.ce, or resicienti~;tl medical care facili.t}'? _ ...........Nr~ -_-......Yes I f <br />so, dates of <admissior~: <br />Dates{s} you treated the patient far condition: <br />