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SUE?JECT: F1IMILY MEDICRI, L~;AVE; (k) PI~1GE 5 <br />6.U7. <br />PAC3 E J. g OF 1 f <br />F~rplain the care needed by the pata.ent, anal why such. care is <br />rnedically neces:~ary: __..__. <br />AI7JTTI~NAI., INFC7b2MATIt7N: :C~~NTZFY QC7ES'I"It7N NC7M[3ER WITH YOUR <br />ADC}T Z'IONAL ANSWEK . <br />5i.clnatux:e of Health Care Provider Date <br />PUBI.,IC BuI?~FN STATEMFiN'i' <br />Tf s~:buiittcd, it is mandatory for employers to retain a copy of C}iz<> <br />di;,closure in their records far three years. 29 U.S.C. § 2b16;2~3 C.F.F2. § <br />825.500. Pes•frons are not required to resporrd to this collectiorx of <br />information unless it cligplays a currently valid QMf3 control Hamner. `3'he <br />Department. of Labor e:xtimates that. it will take arx average of 20 rninut:es <br />tar respondents to earnPlete this collection of information, inc,.l.~.xding the <br />time fo:r reviewing instxuctions, searching existing data se~arc~~s, <br />gathering and maintaining the data needed, and completing and reviewing <br />the collection of, information. If you l-iKxve an}~ camrnents regarding this <br />burden estimate or- any other' aspect of ttxas ccsller.tia n inforrnaticux, <br />including suggestions f.or reducing this harden, send them to the. <br />Admirti:;t:rator, Wade anr3 Nnrrr Division, U. S. De~iartment of L,abcr, Ftoonx ~- <br />3.50'2, 200 Constitution Ave., NW, Washington, DC :>0«>1.0. DO NOT SEND <br />COMPLETED FORM TO THE DEPAr<'tTMENT OF LABOR; RETf)'RN TO 'THE PATYENT <br />