• FMLA Medical Certification Intake Form

    Complete this intake to request HawkFMLA clinician review and upload any employer paperwork or supporting records available to you.

  • Employee Information

  • This form is for HawkFMLA clinician review for FMLA medical certification. Submission or payment does not guarantee certification or employer approval. Please submit only information relevant to this request.

  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Preferred Contact Method*
  • Who is the FMLA leave being requested for?*
  • What type of leave are you requesting?*
    • Employee Health Condition 

    • Employee Health Condition

    • Approximate onset or current episode date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Which job duties are difficult or impossible right now?*
    • Are you currently unable to perform your usual job duties?*
    • Have you already missed work because of this condition?*
    • Family Member Health Condition 

    • Family Member Health Condition

    • Relationship to Employee*
    • Type of Care Needed*
    • Will the Employee Need to Miss Work to Provide Care?*
    • Treatment Information 

    • Treatment Information

    • Has the person with the condition been evaluated by a healthcare professional?*
    • Format: (000) 000-0000.
    • Most recent appointment date
       / /
      2 digit month, 2 digit day, 4 digit year
    • Next appointment date
       / /
      2 digit month, 2 digit day, 4 digit year
    • Has there been hospitalization or inpatient care due to this condition?*
    • Is ongoing or follow-up treatment planned?*
    • Type of Leave being Requested 

    • Continuous Leave

    • Requested first day of continuous leave*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Requested return-to-work date
       / /
      2 digit month, 2 digit day, 4 digit year

    • Intermittent Leave

    • Expected Start Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Estimated End Date of Intermittent Leave (If Known)
       / /
      2 digit month, 2 digit day, 4 digit year

    • Reduced Schedule Leave

    • Expected Start Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Expected Return to Normal Schedule Date
       / /
      2 digit month, 2 digit day, 4 digit year

    • Combination or Unsure Leave

    • Expected leave start date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Estimated end date
       / /
      2 digit month, 2 digit day, 4 digit year
    • Employer FMLA Requirements 

    • Employer FMLA Requirements

    • Employer deadline for completed certification
       / /
      2 digit month, 2 digit day, 4 digit year

    • Document Uploads

    • Has your employer, HR department, or leave administrator provided an FMLA or medical leave form for us to complete?*
    • Upload a File
      Drag and drop files here
      Choose a file
      Cancelof
    • Upload a File
      Drag and drop files here
      Choose a file
      Cancelof

    • Authorization / Acknowledgments

    • Date*
       / /
      2 digit month, 2 digit day, 4 digit year

    • Payment Information

    • - I authorize HawkFMLA to charge my selected payment method for services that I have agreed to pay. I understand that payment is due at the time services are provided or as otherwise communicated by the practice.

      - I authorize HawkFMLA to process the payment information I provide and, when applicable, to charge my payment method for future amounts that I have expressly authorized.

      - I understand that I am responsible for reviewing the charges and notifying HawkFMLA promptly of any questions or discrepancies. 

       

      By selecting “I Agree” below, I confirm that I have read, understood, and voluntarily authorize payment as described above.

    • Payment Information*

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        FMLA Medical Certification


        $179$179
          
        Total
        $0.00$0.00

        Please select a payment method below

        creditcard
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