BE eran soro2e2 oe | Employee: ea fe of Birth: 05-19-1988 Bharathy Selvamai ‘Employer: UBER FREIGHT US ULC ‘ee's Last 4 social security number: XXX- i Funee aco Patient Name: \f jaya larsroni Date of Birth: Relationship to Employee:_ ore. SeWomani Family Member's Serious Health Condition ‘Notes to provider: The FMLA allows an employee (your patient's Family Member") to take time off from work to care for the employee's spouse, son, daughter, or parent with a “serious health condition,” as that term is described in Part B below. Your patient's ‘medical condition may satisfy more than one definition of serious health condition. «= Teésimportant that you complete all sections that apply in Parts A through D in order to ensure your patient's Family Member the ‘most appropriate FMLA leave. ‘+ Limit your answers to the specific health condition of your patient for which the Family Member is seeking leave * If.your patient has more than one unrelated serious health condition that may require leave, complete a separate form foreach condition RMATION | 1. Approximate date your patients condition started or will start for this leave request: 10 /07/.2024 2. Probable duration of your patients condition: _2_pnonties | 3. Most recent 2 dates you have treated your patient for this condition: 0/13/24 and (O/0/ 24 PART B: SERIOUS HEALTH CONDITION - Paragraphs 4-10, continued on next page. Check and complete all sections that apply. ‘4. [Yes GANo Impatient Care: Patient has had an overnight stay ina hospital residential treatment facility, or hospice [ad Admission Date Release Date: 5. [lYes [No Pregnancy: Patient is incapacitated due to pregnancy or in need of care during prenatal care. a) Estimated Due Date: _/_/. 6 Incapacity Plus Treatment (“Incapacity’ means the patient's inability to work, attend school. or perform other regular daily activities due to the serious heath condition, treatment, or recovery) 18) [ives [Jo Patient's period of incapacity has exceeded or will exceed 3 days b) Gites E)No Patient has required or will require atleast 2 office visits within 30 days ofthe frst day’of incapacity 9) Gi¥es No Patient requires 1 office visit resulting in a regimen of continuing treatment (eg, prescription ‘medications or therapy under the supervision ofa healthcare provider). 4), Date of first treatment for this condition: 2/8/24 {Date of most recent treatment for this condition; 4/13/24 {| Date of next scheduled appointment for this condition: 12/14/24 {g)_ Has your patient been prescribed medication fortis condition other than over-the-counter? Fa{Yes C1No 'h) Has your patient been referred to other health care provider(s) for evaluation or treatment for this condition (such as fo yes, state the nature and expected duration of su pine herp EY i ate the nature and expect ! Reg a © menthS ‘SERIOUS HEALTH CONDITIONS CONTINUED ON NEXT PAGE HB ker 4710-6910202 rer4710-6910202REF 4710-6910202 neeari0-6o10202 A SERIOUS HEALTH CONDITIONS CONT FROM PREVIOUS PAGE 7. Pfves (No chronic Condition: Requires at least = over an extended pero of te, nd may cs psa rather tava conte prod ei rae continu ene) & Gifes CNo _Permanentor Long Term Coneltion: May not equetreutmont ut requires superson ft heaen care provider (eg. Alzheimer Disease, terminal illness, severe stroke). 9. [aes [C]No Conditions Requiring Multiple Treatments: Period of ncapacey to rectvemultiple treatments andto_| recover from treatments or ether (1) a condition that would require incapacty for more chan 3 days inthe absenceof medical. intervention or treatment (eg. chemotherapy, dialysis or physical therapy for severe arthritis) or (2) restorative surgery after an accident or injury. 10. [JTF NONE OF THE CONDITIONS IN 4-9 ABOVE APPLY, CHECK HERE. If you check this box, top here, sign the form at _the bottom, and return. PART C: AMOUNT AND TYPE(S) OF LEAVE NEEDED. Notes: + For the following questions please provide your best estimate of frequency and duration, = _"Unkn “as needed,” or “undetermined” may not be sufficient to determine FMLA coverage. SELECT ONE OR MORE IF APPLICABLE - Example: A Family Member may need to provide care that will require: * continuous period of leave for the patients surgery and initial recovery, then. * azeduced schedule of 6 hours per day for X weeks to provide further care during recovery, then. * intermittent leave to take your patient to follow-up appointments or treatment 11. CONTINUOUS LEAVE {ifapplicable}- 8) Bi¥es CINo Patient will need care fora single continuous period of time due to his/her serious health condition. b) Start date ofthis leave:0./01/24 End date of this eaves /.UL/ 25 12. REDUCED SCHEDULE (if applicable): a) C¥es [No Patient needs care cha requires the Family Member to reduce the number of work hous per day or per week from his/her daily or weekly work schedule. b) Reduced Schedule (ifapplicable}: Start date: _/__/___ End date: _/__/__ ) Patient needs care as follows: ___days per week AND ___ hours] perday OR C) per week 13. INTERMITTENT LEAVE (if applicable): a) Dyes [No Patient needs care in intermittent periods of time due to flare-ups of patient's condition. ») Antermitent Leave (i applicable Start date: _/__/___Bnd.date: _/_/_ ©) Estimated FREQUENCY of episodes (how often will the Family Member need to be off work due toa flare-up of the patient's condition?) —— Wepisodes PER Week oR Month oR — Dvear 44) Estimated DURATION of each episode (H) Cours 98 — CAbays LANSWER THE FOLLOWING QUESTIONS FOR REDUCED SCHEDULE OR INTERMITTENT LEAVE ONLY: __| HB ter 4710-6910202 ners7t0-6910282BB er 4710-6910282 ner 4710-6910202 14, Explain why itis medically necessary forthe Family member to provide care on a reduced schedule or take intermittent leave epee! 15, Is tmedicaly necessary for your patient to attend treatmentor follow-up appointments? WZ Yes CINo yes provide the information requested in 16 ~ 18 for medically necessary appointments: 416, Provide an estimated schedule for appointments fr treatments and therapy, including ane eceeteeeens (18 24 rey 24 Uy 25. 24 17, Estimated frequency of unscheduled appointments: Once Every month 18. Estimated duration of each appointment, including recovery time ifneeded ( but not travel time): ) hr 10 ¥2 PART D: MEDICAL FACTS, TREATMENT, and CARE NEEDED Your patient's Family Member may be entitled to time off under the FMLA or tate law ifyour patient sin need of physical care such as ‘assistance with basic medical, hygienic, nutritional, safety, or transportation needs or the provision of psychological care such as. ‘comfort and reassurance which would be beneficial to your patient when receiving inpatient or home care. 19. Dyes [No Isyour patient in need of physical care as described above? Ifyes, explain the care needed by your patient ‘and why such care is medically necessary:REF 4710-6910282 REF 4710-6910282 22, Additional information relevant to your patient's need for care by the Family Member: xed) medicod ve t bok Patient for voqule’ Tae VESiol Provider name: ‘Area of practice: Address: city: State: _ Zip code: Phone: Fax: Signature: Date: ‘PARTE: TO BE COMPLETED BY EMPLOYEE - STATEMENT OF CARE 23. The Family Members your: « Spouse Parent © Child, Under Age 18 © Child, age 18 or older and incapable of self-care because of mental or physical disability SoS eoh ag cee C, loctor_ Vit 3 nef fis aa of —he sat ee a Keep. 25. Indicate how much time away from work will you need to provide the care described above: Ths hecdrent