CERTIFICATION OF HEALTH CARE PROVIDER FAMILY AND MEDICAL LEAVE ACT

Any period of absence to receive multiple treatments (including any period of recovery therefrom) by a health care provider or by a provider of health care services under orders of,

I authorize Health Services at the Center for Health and Wellness to contact my health care provider about any information requiring clarification from my medical

therefrom) by a health care provider or by a provider of health care services under orders of, or on referral by, a health care provider, either for restorative surgery after

care provider or by a provider of health care services under orders of, or on referral by, a health care provider, either for restorative surgery after an accident or other injury,

INSTRUCTIONS to the Administrator: The Family and Medical Leave Act (“FMLA”) provides that an employer require an employee seeking FMLA protections because of a need for leave

Any period of absence to receive multiple treatments (including any period of recovery there from) by a health care' provider or by a provider of health care services under orders

Any period of absence to receive multiple treatments (including any period of recovery therefrom) by a health care provider, or by a provider of health care services under orders

“Provider” - Any person or legal entity, including a managed care organization and their subcontractors, furnishing Medicaid services under a State Health-Care Program