Federal and WA Family Medical Leave Intake Form
This form is used to gather patient and family member details for medical leave application under the Federal Medical Leave Act and WA Paid Family and Medical Leave. It includes sections for patient information, care description, and work status history. The form helps in processing the medical leave efficiently.
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How do I fill this out?
To fill out this form, start by providing the patient and family member information. Then, describe the medical condition and provide the details of care required. Finally, provide work status and treatment information.
How to fill out the Federal and WA Family Medical Leave Intake Form?
1
Provide patient and family member information.
2
Describe the medical condition and care needed.
3
Include work status and treatment details.
4
Sign the acknowledgment section.
5
Submit the form as directed.
Who needs the Federal and WA Family Medical Leave Intake Form?
1
Employees applying for medical leave need this form to provide necessary information.
2
Family members caring for a patient can use this form to describe the care they provide.
3
Employers may require this form to process employee leave requests.
4
Doctors can use this form to document the patient's medical condition.
5
Legal guardians may need this form to apply for leave on behalf of minors.
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What are the instructions for submitting this form?
Submit the completed form via the following options: Fax to the provided fax number, mail to the specified address, or pick up in person as indicated in the form. Ensure all required fields are accurately filled out and signed. Allow up to fifteen calendar days for processing. For assistance, contact Kaiser Permanente directly. Ensure to follow specific guidelines and deadlines for submission to avoid delays or denial of your application.
What are the important dates for this form in 2024 and 2025?
Please check the latest guidelines and deadlines for submission in 2024 and 2025 provided by Kaiser Permanente and relevant authorities.
What is the purpose of this form?
The purpose of this form is to gather essential information for processing medical leave applications under the Federal Medical Leave Act and WA Paid Family and Medical Leave. It includes sections for patient and family member details, medical condition description, care needed, and work status. This form facilitates a streamlined process for obtaining necessary medical leave and ensures all relevant information is provided.
Tell me about this form and its components and fields line-by-line.
- 1. Patient information: Captures personal details of the patient including name and date of birth.
- 2. Family member information: Includes details about the family member such as name and phone number.
- 3. Medical condition: Requires a description of the condition, diagnosis, and care provided.
- 4. Work status history: Captures the work history of the family member including employer name and type of leave.
- 5. Treatment information: Includes details about the medical treatment, duration, and frequency.
- 6. Signature and acknowledgment: Requires the patient’s or legal guardian’s signature to validate the information provided.
- 7. Delivery method/recipient: Details how and to whom the form should be delivered including options for secure member account, fax, mail, or in-person pick-up.
What happens if I fail to submit this form?
Failing to submit this form may result in a delay or denial of the medical leave application. It is crucial to provide accurate and complete information within the specified timeframe.
- Delay in Processing: Failure to submit the form on time can lead to delays in leave approval.
- Denial of Leave: Incorrect or incomplete information may result in the denial of the medical leave application.
- Loss of Benefits: Not submitting the form can lead to the loss of entitled medical leave benefits.
How do I know when to use this form?
- 1. Applying for Medical Leave: Use this form to provide details for obtaining medical leave benefits.
- 2. Providing Family Care: Family members can describe the care provided to the patient using this form.
- 3. Medical Condition Documentation: Clinicians can document the patient's medical condition for leave purposes.
- 4. Employer Verification: Employers may need this form to verify the details of the leave request.
- 5. Legal Guardianship: Legal guardians can use this form to apply for leave on behalf of minors.
Frequently Asked Questions
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Begin by opening the form in PrintFriendly's editor and entering the patient and family member information.
Can I save my progress on the form?
Yes, you can save your changes and download the form at any time.
How do I sign the form?
Use the digital signature feature in PrintFriendly's editor to sign the form.
Can I share the completed form?
Yes, you can share the form via email or a shareable link directly from PrintFriendly.
Do I need to print the form?
No, you can save and share the form digitally.
Is the form compatible with all PDF editors?
The form is best edited using PrintFriendly's PDF editor.
How do I submit the form?
Follow the instructions provided on the form to submit via fax, mail, or in person.
Can I use this form for other types of leave?
This form is specifically for Federal Medical Leave Act and WA Paid Family and Medical Leave.
How long does it take to process the form?
Kaiser Permanente Washington requires up to fifteen calendar days for processing all forms.
Who needs to sign the acknowledgment?
The patient, parent, legal guardian, or person with legal power of attorney must sign the acknowledgment.
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