Request for FMLA (Family Medical Leave Act) Leave should be submitted no less than 30 days prior to the need for leave for a known medical condition or as soon as practicable if unknown.  The form should be completed for your own or a covered family members serious health condition and faxed to (313) 748-6119.   Leaves cannot be approved until a complete and sufficient Certification of Health Care Provider form has been received and reviewed.

This form is to be completed by your physician and submitted within 15 calendar days of your leave request form.  Your physician should fax the fully completed form to (313) 748-6119.  Leaves cannot be approved until a complete and sufficient Certification of Health Care Provider form has been received and reviewed.

This form is to be completed by your covered family member's physician and submitted within 15 calendar days of your leave request form.  Your physician should fax the fully completed form to (313) 748-6119.  Leaves cannot be approved until a complete and sufficient Certification of Health Care Provider form has been received and reviewed.

Please note, a separate form is required for each covered family member, they should not be noted on the same form.

A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes written documentation confirming a military member’s covered active duty or call to covered active duty status. Please check one of the following and attach the indicated document to support that the military member is on covered active duty or called to covered active duty status.

Section II is to be completed by a UNITED STATES DEPARTMENT OF DEFENSE (“DOD”) HEALTH CARE PROVIDER or a HEALTH CARE PROVIDER who is either: (1) a United States Department of Veterans Affairs (“VA”) health care provider; (2) a DOD TRICARE network authorized private health care provider; (3) a DOD non-network TRICARE authorized private health care provider; or (4) a health care provider as defined in 29 CFR 825.125

The FMLA permits an employer to require that an employee submit a timely, complete, and sufficient certification to support a request for military caregiver leave under the FMLA leave due to a serious injury or illness of a covered veteran. If requested by the employer, your response is required to obtain or retain the benefit of FMLA-protected leave. 29 U.S.C. 2613, 2614(c)(3). Failure to do so may result in a denial of an employee’s FMLA request.

SECTION II: For completion by: (1) a United States Department of Defense (“DOD”) health care provider; (2) a United States Department of Veterans Affairs (“VA”) health care provider; (3) a DOD TRICARE network authorized private health care provider; (4) a DOD non-network TRICARE authorized private health care provider; or (5) a health care provider as defined in 29 CFR 825.125.