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Fmla request california Form: What You Should Know
Leave and Allowance Request Form : This forms may be submitted to any health care provider. 3. Claim of Benefits for Family and Medical Leave If the claim does not qualify under Section 52 of the FMLA as to a medical condition: I request the form for the health care professional designated (not registered) by my coverage plan (HMO/ COBRA/PPO/PP/M/CA/MD/TN/NV/FL). 4. Leave and Allowance Request Form: This form is to be completed by either my health care professional physician (physician) or the healthcare professional designated by the insurance provider. The Department of Labor requires the following information and documentation under Sections 60 and 66 of the FMLA for all requests for FMLA leave due to the effects of domestic abuse, family or sex-specific violence or sexual assault of a spouse or dependent child. If the medical conditions can be reasonably expected to be the result of: 1) Physical abuse, domestic violence or sexual assault of a spouse or child, or 2) Sexual assault of a spouse or child, your health, health care professional must: (a) Describe the physical abuse, domestic violence or sexual assault, (b) Describe the condition if it can be reasonably expected to result in the inability to have physical or mental health care, (c) Describe how long the condition has impaired the ability to provide care (physician must complete the statement within 6 months of the event), (d) State if the condition is expected to be the reason for continued leave, and (e) Describe the expected date or dates of the cessation of physical and/or mental health care. For medical professionals who are covered under the Social Security Act, an employee representative must submit an application stating the name, occupation, and address of each individual covered under the plan, and also the name and address of each spouse, if any, and the expected duration in which the employee will be providing benefits to the member, spouse or dependent child. The Department of Labor requires the following information and documentation under Sections 64 and 67 of the FMLA for all requests for FMLA leave due to the effects of domestic abuse, family or sex-specific violence or sexual assault of a spouse or dependent child.
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