The Essential Guide to Family & Medical Leave

appendix C | forms and checklists | 379
Request for Medical Certification
To: [employee’s name]
From: [manager’s name]
Date: [today’s date]
On [date], you informed us of your need to take leave for a serious health condition.
You will be required to submit a medical certification of a serious health condition
from [your or your [family member]’s] health care provider. The medical certification
form is attached to this letter. Please note that you will have to complete a portion of
the form if you are seeking leave to care for a family member.
You must return this form to us by [date 15 calendar days after employee receives the
letter]. If you fail to return this form on time, we may delay the start of your leave, or
postpone the continuation of your leave, until we receive your certification. If you
are unable to return the form on time due to circumstances beyond your control,
please contact me right away.
Feel free to contact me if you have any questions about this requirement.
Sincerely,
[your name]
[date]