Author: Barton A. Bixenstine, Vorys, Sater, Seymour and Pease LLP

When to Use This Form

The FMLA generally permits the employer to contact an employee's health care provider for purposes of obtaining clarification or authentication of a medical certification. Before making such contact for clarification purposes, the employer must obtain a release from the employee (or the employee's family member) that is compliant with the Health Insurance Portability and Accountability Act (HIPAA).

While an employee may choose to provide the release, the employee cannot be required to provide it. Also, once an employee provides a medical certification, this form can be used only for obtaining clarification of that certification after the employer has given the employee an opportunity to cure any deficiencies - once again, the employee cannot be required to provide this authorization even for that limited purpose.

Below is a model form that should be further tailored to fit the employer's specific needs