AMOUNT OF CARE NEEDED. When answering these questions, keep in mind that your patient’s need for care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or transportation needs, or the provision of physical or psychological care.
AMOUNT OF CARE NEEDED. When answering these questions, keep in mind that your patient’s need for care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or transportation needs, or the provision of physical or psychological care. Will the patient be incapacitated for a single continuous period of time, including any time for treatment and recovery? No Yes Estimate the beginning and ending dates for the period of incapacity: During this time, will the patient need care? No Yes Explain the care needed by the patient and why such care is medically necessary: Will the patient require follow-up treatments, including any time for recovery? No Yes Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period: Explain the care needed by the patient, and why such care is medically necessary: Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery? No Yes Estimate the hours the patient needs care on an intermittent basis, if any: hour(s) per day; day(s) per week from through Explain the care needed by the patient, and why such care is medically necessary: Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily activities? No Yes Based upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of 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 week(s) month(s) Duration: hours or day(s) per episode Does the patient need care during these flare-ups? No Yes Explain the care needed by the patient, and why such care is medically necessary: ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER: Signature of Health Care Provider Date APPENDIX H BUMPING CORRIDORS EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES AGENCIES Direct Services Licensed Practical Nurse Mental Health Worker Developmental Services Worker Music Therapist Nursing Assistant Occupational Therapist Aide Occupational Therapist Assistant Physical Therapist Aide Physical Therapist Assistant Recreational Therapist Respiratory Technician Special Service Assistant Speech Therapist Assistant Vocational Instructor Volunteer Services Coordinator X-Ray Technician Public Safety Campus Police Chief Cam...
