Records, forms and certifications

If medically appropriate, a medical certification form can be submitted to an employer or leave administrator to determine your eligibility for:

• Family and Medical Leave Act (FMLA)
• Oregon Family Leave Act (OFLA)
• Paid Leave Oregon (PLO)
• Washington Paid Family and Medical Leave (PFML)

FMLA and OFLA protect your absence from work due to a serious health condition to care for yourself or an eligible family member. PLO and PFML provide financial benefits in addition to work leave protection.

All four programs accept the federal FMLA medical certification form Kaiser Permanente will provide. No other forms are required. Refer to your employer or leave administrator for details on your organization’s policies on timing for requesting leave and how to submit your form.

If YOU are the patient (not a proxy), read the instructions below then click the link Request FMLA Medical Certification to enter your request. If you are a proxy, call 503-571-5051 to make the request.

1. Do not submit forms directly to your clinician. Requests submitted through the link below or via phone will be routed to your clinician for review. The amount of time certified is based on in-depth review of your medical record and may not always reflect your original request.
2. The completed form will appear in the patient’s KP.org account in the Letters section within 7 days. An email notification will be sent to the patient via KP.org.
3. To direct the form to a third party, use the third-party distribution option when completing your request or follow the instructions supplied in a phone request.
4. HOW TO DOWNLOAD A MEDICAL CERTIFICATION FORM FROM KP.org:
   
   
   1. Log into your KP.org account on a computer or on a mobile phone using the web browser. Do not use the KP mobile app, as it does not support printing.
   2. Choose Medical Record and then the Letters section.
   3. Select the document named FMLA Letter. It is 4 pages in length with a red, white, and blue logo in the upper right corner of the first page.
   4. Choose Print and select PDF format.
   5. Save the form to your computer or mobile phone files, renaming it as needed so you can locate it when you either attach it to an email or upload it to your state paid leave website.
   6. If you are using a mobile phone and cannot see the Print command, turn the phone sideways to landscape view as the Print command is in the upper right corner and may not be visible in portrait view.

Request FMLA Medical Certification

These definitions will assist you in making your request:

Continuous leave: A leave of more than three (3) consecutive days for your own serious health condition or to care for a family member with a serious health condition.

Intermittent leave: Leave taken in separate blocks of time due to a serious health condition, such as flare-ups of a chronic condition. You must provide details about the frequency of flare-ups, e.g., number of episodes per month and duration of episodes. A reduced work schedule also falls under intermittent leave.

Parental leave for baby bonding: Parental leave is an entitlement and does not require medical certification nor is your clinician’s signature required. You only need to provide proof of birth, such as a birth certificate, hospital discharge paperwork, or after-visit summaries.

Modification of an existing leave: If any of the above requests require modification after they have already been approved, please contact your clinical team to have your work status updated.

Short-term and long-term disability coverage protect employees when they are off the job for a period of time due to illness or injury. These benefits are typically provided through an insurance carrier designated by your employer, who will supply you with a form. Kaiser Permanente will substitute a universal attending physician statement that your disability carrier will accept.

Complete the following:

• Submit the form provided to you by your disability carrier.
• INCLUDE the first date you were unable to work and the day you expect to be able to return to work.
  
• INCLUDE a signed authorization form to permit the transmission of your completed form(s) to your insurance carrier. Clear photographs of forms are acceptable.
• INCLUDE your disability claim number if you have one.
• Email all forms to nw.roi@kp.org. Clear photographs of forms are acceptable.

Forms submitted with incomplete information will significantly delay processing of your request.

If you are on leave for a continuous period of time, you may need medical clearance from your clinician before you return to work. If you require a release to return to work, please complete the following steps:

• Contact your clinical team via kp.org message to request a Work Status Report or “return to work” note, or make this request by phone to your clinical team (obtain their phone number via kp.org or by calling 503-813-2000 or 800-813-2000). In some cases, you may need to schedule an appointment. In your Work Status Report, your clinician may specify any potential limitations you require during your transition to regular duties.
• Your clinician will make your Work Status Report available as a letter on kp.org or make arrangements for you to pick it up.
• You are responsible for providing your release to your employer.

Under the Americans with Disabilities Act (ADA), employers are required to provide reasonable accommodations to qualified employees with disabilities, unless doing so would pose an undue hardship. A reasonable accommodation is defined as assistance or changes to a position or workplace that will enable an employee to do his or her job despite having a disability.

If you require an accommodation, please complete the following steps:

• Contact your employer, who will either provide a document for your clinical team to complete or direct you on next steps. In some cases, you may need to schedule an appointment.
• If you are given a form by your employer, use kp.org to message your clinical team or call them (obtain their phone number via kp.org or by calling 503-813-2000 or 800-813-2000) for further instructions.

Do not send ADA paperwork to the Release of Information department as that will delay your request.