FMLA Source Form

Attention: Your selected action will end the Leave Request process and you will lose all entered data.

Return the completed form via fax to FMLASource at 1.877.309.0218 before the listed due date. If you do not complete all steps in full, FMLASource will contact you again to cure any deficiencies or your patient’s family member’s leave may be denied. Completing the …

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FMLASource is a ComPsych Corporation company that specializes in reviewing, approving, processing and tracking FMLA leave requests with the oversight of expert legal staff. FMLASource helps assure compliance with state and federal law, consistency in processing and coordination, and facilitates communication to supervisors, managers, HR and employees. FMLASource is …

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I request the following forms for my FMLA leave of absence: 1. Certification of Health Care Provider: This form is to be completed by either my health care provider (if this leave is for my own serious health condition) or by my family member’s health care provider (if this leave is for the serious health condition of a spouse, parent, or child). My physician must complete this entire …

of absence can be a form of accommodation. If an employee exhausts all of their FMLA hours or did not qualify for FMLA this is another option that protects the employee’s position. How can I apply for FMLA? To apply for FMLA you must contact FMLASource. You can contact them by calling 1-877-462-3652. You can also go online, www.fmlasource.com. When should I contact …

Then, confirm your desired form of correspondence with FMLASource. … If you are eligible for FMLA, you will receive a Leave Request Packet and Medical Certification via email within 48 hours. If you chose the postal option, it may take several days to receive your Leave Packet and Medical Certification. If you have an appointment with your health care provider within the next …

Medical Certification for FMLA – Employee Your Healthcare Provider/ Case Worker must complete and return this form to FMLASource by Confidential fax: 877-309-0218 or Mail: FMLASource, 455 N. Cityfront Plaza Drive, Chicago, IL 60611-5322 Name: FMLA Claim Number: Company Name: Healthcare Provider please return form directly to: I, (Health Care Provider/ …