Page 3 of 5 Fs/f PFML-CERT-FORM (12/21) Employee - First Name Middle Name Last Name Claim Number In the space provided below or in an attached page, please describe the care needed for the patient and why such care is medically necessary. If care is for an adult child, List ADLs or IADLs your patient requires support to perform (i.e., cooking, toileting, travel to appointments) . Please Read: GINA Disclaimer: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. Genetic Information as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. Fraud Notice: Any person who knowingly and with intent to injure, defraud, or deceive any person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information is/may be guilty of a crime and may be prosecuted and punished. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. By signing below, I attest that I am the treating health care provider to the listed patient. The clinical information I am providing is in regard to the dates of absences listed above. I certify that my patient’s family member (employee) must be absent from work or have a modified work schedule due to this condition. License Number State Business Name Address City State ZIP Phone Number Email Signature of Heathcare Provider Date (mm/dd/yyyy)