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SUBJECT: FAi'~9ILY MEDICAL LEAVE ACT' (E) PAGI; 2 g.r? <br />F5AG1J 1 I ~JF 1 ~;+ <br />SECTION III: For completion by the HEALTH CARE PROVIDER INSTRUCTIONS <br />to the HEALTH CARE PROVIDER: Your patient has requested leave ur~dez° <br />the FM;.,A. Answer, fully and completely, all applicable pants. <br />SevEar<~l questions seek a resporxse as to the frequency ar duration of a <br />r_ondition, treatment, etc, Your answer should be your best estimate <br />based up~~r~ your medical knowledge, expex°ence, and examination of the <br />patient. Fie as specific as you can; terms such as "lifetime,,' <br />"unknown," or "indeterminate" may not be sufficient to determine T'MI.A <br />cover-age. Limit your responses to the candition for which thE~ <br />employee is seekinzl leave, Please be sure to sign the form on the <br />last patFe . <br />i~rovider's ;;ame anal business addx:ess: <br />Type of practice/Medical specialty: <br />`Pe l~ pliorie : t f <br />Fa:x: { S <br />PAR';` A : ME'D I CAL EAC'I'S <br />1. Appioxirnate date condition commenced: <br />Prabable duratian of condition: <br />Mark below as applicable: <br />Way; tl~~e patient admitted for an averr7ight st~xy irx a lxospit.~l, <br />hos~pi.ce, or residential medical care facility? Na Yes I.t <br />:~o, dates of admissiorX: ___._ __-__ <br />Dateu) you t.reat.ed the patient far candit.i.an: <br />Will the patient need to have trc~atmc~nt visits at least twice per <br />year due to the condition? IVO Yes <br />Was mc~dieatian, other than aver°-the-counter medicatior;, <br />prescribed? No Yes <br />Way the patient referred to other health care pravidc~r(s) far <br />evaluation ai treatment {~•g~_r Physical therapist)? ~ C~a <br />Ya..s If: sa, :state the nature of sue~h treatment :s and c~xpecte-d <br />duration of treatment: <br />