October 14, 2020
YORK_START
Ferhana B Hassen
14181 Noel Rd
Apt 7306
DALLAS, TX 75254
Claim No: 2020-0070946
Employer: Parkland
Re: Family and Medical Leave Act (FMLA) Benefits - Extension Request
Dear Ferhana:
This letter is to follow up on your Continuous leave under FMLA for your leave reason of
Family Care from October 9, 2020 through October 30, 2020.
Please be advised that your leave will expire on October 30, 2020. In order to extend your
FMLA claim for an additional period of time, we are requesting you provide the following:
● Enclosed Certification of Health Care Provider Form, which needs to be completed by your
health care provider
● Your health care provider can update the original certification and initial and date by any
changes
Please return it to Sedgwick by November 2, 2020. Failure to do so may result in your
continued FMLA leave being delayed and no longer providing job protection until certification
is received.
Failure to provide this documentation could result in an unexcused absence(s) and your
absence(s) will be subject to the normal Parkland Attendance Policy in the Employee
Handbook.
The completed documentation can be sent to Sedgwick via our secure toll-free fax number at
(888) 436-9535.
Thank you for your prompt attention. Should you have any questions, please feel free to
contact me at our toll free telephone number, (844) 263-3117, Extension 50079 to discuss
any questions.
Sincerely,
Thomas Maya
Disability Claim Specialist
Enclosure(s): Certification of Health Care Provider for Family Member's Serious Health
Condition (FMLA)
Extension Request Letter York Risk Services Group, Inc., a Sedgwick company Page 1 of 2
Extension Request Letter York Risk Services Group, Inc., a Sedgwick company Page 2 of 2
2020-0070946
Certification of Health Care Provider for U.S. Department of Labor
Family Member’s Serious Health Condition Wage and Hour Division
(Family and Medical Leave Act)
____________________________________________________________________________________________________________________________________________________________________________________________________________
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT. OMB Control Number: 1235-0003
Expires: 8/31/2021
SECTION I: For Completion by the EMPLOYER
INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer
may require an employee seeking FMLA protections because of a need for leave to care for a covered family
member with a serious health condition to submit a medical certification issued by the health care provider of the
covered family member. Please complete Section I before giving this form to your employee. Your response is
voluntary. While you are not required to use this form, you may not ask the employee to provide more information
than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306-825.308. Employers must generally maintain
records and documents relating to medical certifications, recertifications, or medical histories of employees’ family
members, created for FMLA purposes as confidential medical records in separate files/records from the usual
personnel files and in accordance with 29 C.F.R. § 1630.14(c)(1), if the Americans with Disabilities Act applies,
and in accordance with 29 C.F.R. § 1635.9, if the Genetic Information Nondiscrimination Act applies.
Employer name and contact: _____________________________________________________________________
Parkland
Thomas Maya
__________________________________________________________________________________________________________________________________________________
SECTION II: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your family
member or his/her medical provider. The FMLA permits an employer to require that you submit a timely,
complete, and sufficient medical certification to support a request for FMLA leave to care for a covered family
member with a serious health condition. If requested by your employer, your response is required to obtain or
retain the benefit of FMLA protections. 29 U.S.C. §§ 2613, 2614(c)(3). Failure to provide a complete and
sufficient medical certification may result in a denial of your FMLA request. 29 C.F.R. § 825.313. Your employer
must give you at least 15 calendar days to return this form to your employer. 29 C.F.R. § 825.305.
Your name: __________________________________________________________________________________
Ferhana Hassen
First Middle Last
Name of family member for whom you will provide care:______________________________________________
First Middle Last
Relationship of family member to you: _____________________________________________________________
If family member is your son or daughter, date of birth:_____________________________________________
Describe care you will provide to your family member and estimate leave needed to provide care:
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
________________________________________________ _________________________________________
Employee Signature Date
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2020-0070946
SECTION III: For Completion by the HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested leave under
the FMLA to care for your patient. Answer, fully and completely, all applicable parts below. Several questions
seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best
estimate based upon your medical knowledge, experience, and examination of the patient. Be as specific as you
can; terms such as “lifetime,” “unknown,” or “indeterminate” may not be sufficient to determine FMLA
coverage. Limit your responses to the condition for which the patient needs leave. Do not provide information
about genetic tests, as defined in 29 C.F.R. § 1635.3(f), or genetic services, as defined in 29 C.F.R. § 1635.3(e).
Page 3 provides space for additional information, should you need it. Please be sure to sign the form on the last
page.
Provider’s name and business address:______________________________________________________________
Type of practice / Medical specialty: ______________________________________________________________
Telephone: (________)____________________________ Fax:(_________)_______________________________
PART A: MEDICAL FACTS
1. Approximate date condition commenced: _________________________________________________________
Probable duration of condition: _________________________________________________________________
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
___No ___Yes. If so, dates of admission: _______________________________________________________
Date(s) you treated the patient for condition: ______________________________________________________
Was medication, other than over-the-counter medication, prescribed? ___No ___Yes.
Will the patient need to have treatment visits at least twice per year due to the condition? ___No ____ Yes
Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)?
____ No ____Yes. If so, state the nature of such treatments and expected duration of treatment:
2. Is the medical condition pregnancy? ___No ___Yes. If so, expected delivery date: ______________________
3. Describe other relevant medical facts, if any, related to the condition for which the patient needs care (such
medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of
specialized equipment):
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2020-0070946
PART B: AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that your patient’s need
for care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or
transportation needs, or the provision of physical or psychological care:
4. Will the patient be incapacitated for a single continuous period of time, including any time for treatment and
recovery? ___No ___Yes.
Estimate the beginning and ending dates for the period of incapacity: ___________________________________
During this time, will the patient need care? __ No __ Yes.
Explain the care needed by the patient and why such care is medically necessary:
5. Will the patient require follow-up treatments, including any time for recovery? ___No ___Yes.
Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for
each appointment, including any recovery period:
__________________________________________________________________________________________
Explain the care needed by the patient, and why such care is medically necessary: ________________________
6. Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery? __
No __ Yes.
Estimate the hours the patient needs care on an intermittent basis, if any:
________ hour(s) per day; ________ days per week from _________________ through __________________
Explain the care needed by the patient, and why such care is medically necessary:
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2020-0070946
7. Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily
activities? ____No ____Yes.
Based upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of
flare-ups and the duration of related incapacity that the patient may have over the next 6 months (e.g., 1 episode
every 3 months lasting 1-2 days):
Frequency: _____ times per _____ week(s) _____ month(s)
Duration: _____ hours or ___ day(s) per episode
Does the patient need care during these flare-ups? ____ No ____ Yes.
Explain the care needed by the patient, and why such care is medically necessary: ________________________
____ ___
____ ___
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
______________________________________________ ____________________________________________
Signature of Health Care Provider Date
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. § 2616;
29 C.F.R. § 825.500. Persons are not required to respond to this collection of information unless it displays a currently valid OMB
control number. The Department of Labor estimates that it will take an average of 20 minutes for respondents to complete this
collection of information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate
or any other aspect of this collection information, including suggestions for reducing this burden, send them to the Administrator,
Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC 20210.
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.
Page 4 Form WH-380-F Revised May 2015
