Family Medical Leave Act (FMLA) Application Form - Family Member’s Health Condition

Sep 19, 2026

Upload by Gloria

Family Medical Leave Act (FMLA) application form used to document a family member’s health condition for determining eligibility for leave. The employee section collects names, relationship, and a description of the care to be provided with an estimate of leave needed. The health care provider section gathers medical details, treatment dates, admission information, pregnancy status, episodic flare-ups, follow-up necessity, and an estimated schedule, ending with provider signature and date.

LanguageEnglish

CategoryForms

FormatPDF

Pages4

Reading Time2 min

AccessFree to download

TO BE COMPLETED BY EMPLOYEE

Information about the employee and family member

Instructions for the Health Care Provider

Completing applicable sections

TO BE COMPLETED BY THE HEALTH CARE PROVIDER

Medical condition timeline and treatment details

Signature and date

Family Medical Leave Act (FMLA) Application Form for a Family Member’s Health Condition To be completed by you and a licensed health care provider describing the family member’s medical condition for the purpose of determining eligibility for leave under the Family Medical Leave Act. TO BE COMPLETED BY EMPLOYEE First Name: Middle Initial: Last Name: Name of the family member for whom you will provide care: First Name: Middle Initial: Last Name: Relationship of family member to you: If the family member is your son or daughter, date ofbirth: Describe the care you will provide to your family member and estimate the leave needed: Instructions for the Health Care Provider The employee listed above is requesting leave under the Family Medical Leave Act to care for your patient. Please answer, fully and completely all applicable parts of this form. Your answers should be your best estimate based upon your medical knowledge, experience, and examination of the patient. When applicable, circle YES or NO to indicate your response. TO BE COMPLETED BY THE HEALTH CARE PROVIDER Provider’s Name: Type of Practice/Medical Specialty: Telephone: ( ) Fax: ( ) When did the medical condition(s) begin? How long is the condition expected to last? If the condition is permanent, please indicate. Was the patient admitted for an overnight stay in a hospital or residential medical care facility? If yes, what were the dates of admission? What were the dates in which you treated the patient for this condition? Will the patient require treatment at least twice per year due to the condition? YES or NO Was medication, other than over-the-counter medication prescribed? YES or NO Was the patient referred to other health care providers for evaluation or treatment? If yes, please state the nature of the treatments and expected duration of treatment. Is the medical condition pregnancy? YES or NO If yes, expected delivery date: Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave. Will the patient be incapacitated for a single continuous period of time due to this condition, including any time for treatment and recovery? YES or NO If yes, estimate the beginning and ending dates for the period of incapacity: Will the patient require follow-up treatment appointments because of the condition? YES or NO If yes, are the treatments medically necessary? YES or NO Please list the estimated treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period: Will the condition cause episodic flare-ups periodically preventing the employee from performing their essential job functions? YES or NO Is it medically necessary for the patient to receive care during the flare-ups? YES or NO If yes, please explain: Based upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of the 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: weeks/months for: hours or days per episode. Signature of Health Care Provider: Date: When completed please fax this form to (847) 949-4756, with CONFIDENTIAL: ATTND120 HR on the cover page.

FAQs

What information must the employee provide on this FMLA form?

The employee provides their own name, the family member’s name, the relationship to the employee, and details describing the care to be provided along with an estimate of the leave needed.

What medical details does the health care provider need to complete?

The provider records when the condition began, expected duration, whether the patient had overnight admission, treatment dates, frequency of flare-ups, need for follow-up treatment, pregnancy status if applicable, and the estimated treatment schedule.

Where does the form require final confirmation?

The provider must sign and date the form, and when completed it should be faxed to the specified number with CONFIDENTIAL: ATTND120 HR on the cover page.

Sep 19, 2026

Upload by Gloria