Tips to complete your application

Family and Medical Leave: Tips to Complete an FML Application

To assist you, we have identified the areas where incomplete/inadequate information has required re-submissions.

Before faxing the certification form to the Employee Service Center (ESC), ensure your name and file number are indicated on each page. Also, in case a FML certification is faxed upside down, place your UAL file number on the back of each page. This alerts us to contact you and advise you to re-fax the form.

All faxed certification forms should be sent directly from the health care provider’s office.

Ensure you keep a copy of the FML certification for your records. In addition, you may want to keep your fax confirmation sheet to ensure it was sent to the correct fax number and that all pages were sent to the ESC.

If you are eligible for FML, your FML application must also meet the FML criteria as defined by the Department of Labor (DOL). You may view the information on SkyNet which includes a Question and Answer document and FML Overview.

To avoid unnecessary delays of your FML request, please ensure you and your health care provider (HCP) answer all questions on the FML certification fully, completely and are legible.

It is your responsibility to ensure the FML application is received within the 15 calendar days from the first date of the absence in order for that absence to be included in the review of your FML request.

_________________________________________________________________________________

Co-worker (page one):

Section A (Co-worker Information): Your accurate and complete personnel information is needed to ensure we can update your scheduling system, department and FML case. Your work schedule is required as treatments, procedures, etc. must be scheduled outside of your work hours unless documented extenuating circumstances exist.

Section B (FML Request): Be sure to identify whether your request for FML is for your own serious health condition or to care for an eligible dependant of record (i.e. child, parent, spouse, etc.).

Section C (Scheduled Appointments for self/Family member): List the scheduled doctor appointments for the past 3 months up to 1 year.

Section D (Care of Family Member): This section must be completed fully if your request is for the care of an eligible dependent that cannot be accomplished outside of your work hours.

Indicate the type of leave you are requesting:

- - Block – A single consecutive period e.g., 6 calendar days
    - The start date is the beginning date of incapacity and the end date is the last day of incapacity e.g. Start date – June 1, 2011 End date – June 7, 2011. You would return to work on June 8, 2011.

- - Intermittent – re-occurring condition that may require multiple absences
    - An intermittent start date is the first day of when you may have re-occurring absences. This date will be the start date of your FML approval. An intermittent end date is the last day of re-occurring absences. (This date may not exceed 1 year and will be the end date of your FML approval). e.g. Start date – June 1, 2011 End date – June 1, 2012.
      - The frequency is based on the number of times (occurrences) the condition caused incapacity during the last 12 months.
      - The duration is the average number of days the incapacity lasted during a normal occurrence of the condition.

The frequency and duration of incapacity needs to be consistent with the medical history and the condition, treatment plan, prescribed medication, office visits, etc.

Please keep in mind, that the total number of days of incapacitation must also be consistent with your medical history and the condition, treatment plan, prescribed medication, office visits etc. For example, a request for a frequency of 4 times per month for up to five days for each occurrence equals 20 days a month or 240 days per year. Based on the request, we may require additional information to clarify if the condition actually warrants a continuous block of time or is consistent with the stated condition.

This is especially true when the total number of days of incapacity exceeds the number of day in a month, e.g., incapacity of 4 times a month for up to 8 days equals 32 days a month. The total number of days of incapacity is based on the past medical history. The frequency and duration of incapacity needs to be consistent with the condition, treatment plan, prescribed medication, office visits, etc.

Section E (Signature Certification): Based on your signature, you are certifying that all information is true and accurate. Company Working Together Guidelines provide that falsification of documentation may lead to discipline up to and including termination.

Health Care Provider (HCP) (page two and three):

These pages must be competed by your HCP.

Section F (Patient’s Medical Facts and Information): Be sure to have your HCP identify and answer all questions. If the question does not pertain to your FML request, he/she may indicate NA (not applicable).
- Indicate the date you began treatment with your current HCP.
- What was the date your condition was diagnosed?
- Was there an overnight stay in the hospital? Indicate the type of leave being requested.
  - Block – A single consecutive period e.g., 6 calendar days
    - The start date is the beginning date of incapacity and the end date is the last day of incapacity. e.g. Start date – June 1, 2011 End date – June 7, 2011. You would return to work on June 8, 2011.
  - Intermittent – re-occurring condition that may require multiple absence
    - An intermittent start date is the first day of when you may have re-occurring absences. This date will be the start date of your FML approval. An intermittent end date is the last day of re-occurring absences. (This date may not exceed 1 year and will be the end date of your FML approval). e.g. Start date – June 1, 2011 End date – June 1, 2012.
      - The frequency is based on the number of times (occurrences) the condition caused incapacity during the last 12 months.
      - The duration is the average number of days the incapacity lasted during a normal occurrence of the condition.

The frequency and duration of incapacity needs to be consistent with your medical history and the condition, treatment plan, prescribed medication, office visits, etc.

Please keep in mind, that the total number of days of incapacitation must also be consistent with the condition, treatment plan, prescribed medication, office visits etc. For example, a request for a frequency of 4 times per month for up to five days for each occurrence equals 20 days a month or 240 days per year. Based on the request, we may require additional information to clarify if the condition actually warrants a continuous block of time or is consistent with the stated condition.

Section G (Medical Facts): Describe the medical facts of a serious health condition. This may include but is not limited to the patient’s diagnosis, symptoms. e.g. Cancer, amputation, nausea from chemotherapy, numbness or weakness in one or more limbs due to MS, etc.

Please note, if you work in California, this section is optional for you. Your HCP should not disclose the underlying diagnosis on this form without your consent.

Section H: Per the DOL, there are specific requirements to meet the definition of a serious health condition. This includes:

If the request is for intermittent, the patient must have at least 2 treatment visits per year.

If the request is for block, the patient must have been seen within the first seven days of incapacity.

Were you referred to anyone, e.g. neurologist?

Do you have any medication other than over the counter prescribed?

Section I (FML for Employee): List the specific restrictions and work functions the patient is incapable of performing during periods of incapacity.

Section J (FML for Care of a Family Member): Describe the care that must be provided to the patient during the co-worker’s work hours. e.g. wound care, frequent bandage changes, etc

Please note: If the FML request is for care of an adult child (18 or over), the health care provider must list the physical or mental impairment that substantially limits one or more of the major life activities of an individual and describe why the patient is incapable of self-care. This means that the individual requires active assistance or supervision to provide daily self-care in three or more of the “activities of daily living” (ADLs) or “instrumental activities of daily living” (IADLs). Activities of daily living may include caring appropriately for one’s grooming and hygiene, bathing, and eating. IADLs may include driving, preparing meals, and managing medication.

Section K: The HCP must provide his/her Information/date and certify by signature that the information is accurate and factual.

Should you have any questions in regards to your FML application, the ESC is available to you 16 hours a day, seven days a week (including holidays) throughout the year (0700 through 2300 central time).