<table style="width:100%;">
<colgroup>
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 10%" />
<col style="width: 4%" />
<col style="width: 7%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 8%" />
<col style="width: 5%" />
<col style="width: 8%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 11%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="5"><p><em>BPA F 3780.02e</em></p>
<p><em>(08-03)</em></p></td>
<td colspan="12"><p><strong>CERTIFICATION OF HEALTH CARE
PROVIDER</strong></p>
<p><strong>For Serious Health Condition</strong></p></td>
<td colspan="3"><p><em>Electronic Form Approved</em></p>
<p><em>by CIEP – 08/08/2003</em></p></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="15"><em><strong>(Family and Medical Leave Act of 1993 and
Use of Extended Sick Leave under 5 CFR Subpart D)</strong></em></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="11">1. EMPLOYEE’S NAME</td>
<td colspan="9">2. PATIENT’S NAME &amp; RELATION <em>(if different from
employee’s)</em></td>
</tr>
<tr class="even">
<td colspan="11"><strong>     </strong></td>
<td colspan="9"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="20">3. The attached sheet describes what is meant by a
<strong>“serious health condition”</strong> under the Family and Medical
Leave Act and Use of Extended Sick Leave under 5 CFR Subpart D. Does the
patient’s condition<sup>1</sup> qualify under any of the categories
described? If so, please check the applicable category.</td>
</tr>
<tr class="even">
<td></td>
<td>(1)</td>
<td colspan="2"></td>
<td colspan="2">(2)</td>
<td></td>
<td>(3)</td>
<td></td>
<td>(4)</td>
<td colspan="2"></td>
<td>(5)</td>
<td></td>
<td>(6)</td>
<td></td>
<td colspan="3">or None of the above</td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="20">4. Describe the <strong>medical facts</strong> which
support your certification, including a brief statement as to how the
medical facts meet the criteria of one of these categories:</td>
</tr>
<tr class="odd">
<td colspan="20"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="20">5a. State the approximate <strong>date</strong> the
condition commenced, and the probable <strong>duration</strong> of the
condition <em>(and also the probable duration of the patient’s present
<strong>incapacity<sup>2</sup></strong> if different):</em></td>
</tr>
<tr class="odd">
<td colspan="20"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="20">b. Will it be necessary for the employee to work only
<strong>intermittently or to work on a less than full schedule</strong>
as a result of the condition (including for treatment described in Item
6 below)? YES NO If Yes, give the probable duration:</td>
</tr>
<tr class="odd">
<td colspan="20"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="20">c. If the condition is a <strong>chronic
condition</strong> (condition #4), <strong>pregnancy or
childbirth</strong>, state whether the patient is presently
incapacitated and the likely duration and frequency of <strong>episodes
of incapacity<sup>2</sup>.</strong></td>
</tr>
<tr class="odd">
<td colspan="20"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="20">6a. If additional <strong>treatments</strong> will be
required for the condition, provide an estimate of the probable number
of such treatments.</td>
</tr>
<tr class="odd">
<td colspan="20"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="20">If the patient will be absent from work or other daily
activities because of <strong>treatment</strong> on an
<strong>intermittent</strong> or <strong>part-time</strong> basis, also
provide an estimate of the probable number and interval between such
treatments, actual or estimated dates of treatment if known, and period
required for recovery if any:</td>
</tr>
<tr class="odd">
<td colspan="20"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="20">b. If any of these treatments will be provided by
<strong>another provider of health services</strong> <em>(e.g., physical
therapist),</em> please state the nature of the treatments:</td>
</tr>
<tr class="odd">
<td colspan="20"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="20"><ol type="1">
<li><p>Here and elsewhere on this form, the information sought relates
<strong>only</strong> to the condition for which the employee is taking
FMLA or using extended Sick</p></li>
</ol>
<blockquote>
<p>Leave under 5 CFR Subpart D.</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="20"><ol start="2" type="1">
<li><p><strong>“Incapacity”</strong>, for purposes of FMLA or use of
Extended Sick Leave under 5 CFR Subpart D, means the inability to work,
attend school or perform other regular daily activities due to the
serious health condition, treatment therefore or recovery
therefrom.</p></li>
</ol></td>
</tr>
<tr class="even">
<td colspan="20"></td>
</tr>
</tbody>
</table>

FILE CODE: PE-46-13

RETENTION: CHR/CF = SEE DISPOSITION

<table style="width:100%;">
<colgroup>
<col style="width: 13%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 7%" />
<col style="width: 24%" />
<col style="width: 7%" />
<col style="width: 5%" />
<col style="width: 11%" />
<col style="width: 7%" />
<col style="width: 3%" />
<col style="width: 8%" />
<col style="width: 6%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3"><p><em>BPA F 3780.02e</em></p>
<p><em>Page 2</em></p>
<p><em>(08-03)</em></p></td>
<td colspan="6"><p><strong>CERTIFICATION OF HEALTH CARE
PROVIDER</strong></p>
<p><strong>For Serious Medical Condition (cont.)</strong></p></td>
<td colspan="3"><p><em>Electronic Form Approved</em></p>
<p><em>by CIEP – 08/08/2003</em></p></td>
</tr>
<tr class="even">
<td></td>
<td colspan="9"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="12"></td>
</tr>
<tr class="even">
<td colspan="12">c. If a <strong>regimen of continuing
treatment</strong> by the patient is required under your supervision,
provide a general description of such regimen <em>(e.g., prescription
drugs, physical therapy requiring special equipment):</em></td>
</tr>
<tr class="odd">
<td colspan="12"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="12">7a. If medical leave is required for the employee’s
<strong>absence from work</strong> because of the <strong>employee’s own
condition</strong> <em>(including absences due to pregnancy, childbirth,
or a chronic</em> <em>condition),</em> is the employee <strong>unable to
perform work</strong> of any kind?</td>
</tr>
<tr class="odd">
<td colspan="12"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="12">b. If able to perform some work, is the employee
<strong>unable to perform any one or more of the essential functions of
the employee’s job?</strong> <em>(The employee or the employer</em>
<em>should supply you with information about the essential job
functions.)</em> YES NO If yes, please list the essential functions the
employee is unable to perform.</td>
</tr>
<tr class="odd">
<td colspan="12"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="12">c. If neither <strong>a.</strong> nor
<strong>b.</strong> applies, is it necessary for the employee to be
<strong>absent from work for treatment?</strong></td>
</tr>
<tr class="odd">
<td colspan="12"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="12">8a. If leave is required to <strong>care for a family
member</strong> of the employee with a serious health condition,
<strong>does the patient require assistance</strong> for basic medical
or personal needs or safety, or for transportation? YES NO</td>
</tr>
<tr class="odd">
<td colspan="12"></td>
</tr>
<tr class="even">
<td colspan="12">b. If no, would the employee’s presence to provide
<strong>psychological comfort</strong> be beneficial to the patient or
assist in the patient’s recovery?</td>
</tr>
<tr class="odd">
<td colspan="12">YES NO</td>
</tr>
<tr class="even">
<td colspan="12"><ol start="3" type="a">
<li><p>What is the probable period of time the employee will be required
to care for the family member?</p></li>
</ol>
<p><strong>     </strong></p>
<ol start="4" type="a">
<li><p>If the patient will need care <strong>only
intermittently</strong> or on a part-time basis, please indicate the
<strong>probable occurrence</strong> of this need.</p></li>
</ol></td>
</tr>
<tr class="odd">
<td colspan="12"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td></td>
<td colspan="3"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="4"><strong>     </strong></td>
<td></td>
<td colspan="4"><strong>     </strong></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2" rowspan="4"></td>
<td colspan="4" rowspan="4"><em>(Signature of Health Care
Provider)</em></td>
<td></td>
<td colspan="4"><em>(Type of Practice)</em></td>
<td></td>
</tr>
<tr class="odd">
<td rowspan="3"></td>
<td colspan="4" rowspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td></td>
</tr>
<tr class="odd">
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="4"><strong>     </strong></td>
<td></td>
<td colspan="4"><strong>     </strong></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="4"><em>(Address)</em></td>
<td></td>
<td colspan="4"><em>(Telephone Number)</em></td>
<td></td>
</tr>
<tr class="even">
<td colspan="12"></td>
</tr>
<tr class="odd">
<td colspan="12"><strong>(Note: If invoking FMLA entitlement, employee
must also submit BPA F 3510.04e, Application for Leave Under the Family
and Medical Leave Act)</strong></td>
</tr>
<tr class="even">
<td colspan="12"></td>
</tr>
<tr class="odd">
<td colspan="12"><p><strong>To be completed by the employee needing
family leave to care for a family member:</strong></p>
<p>State the care you will provide and an estimate of the period during
which care will be provided, including a schedule if leave is to be
taken intermittently or if it will be necessary for you to work
<strong>less than a full schedule</strong>. (Submit this form to your
supervisor/manager. Original to Medical Program Manager, CHM-1, copy to
be retained in a secure file in Manager’s office)</p></td>
</tr>
<tr class="even">
<td colspan="2" rowspan="5"></td>
<td colspan="4" rowspan="5"></td>
<td></td>
<td colspan="4" rowspan="5"></td>
<td rowspan="5"></td>
</tr>
<tr class="odd">
<td></td>
</tr>
<tr class="even">
<td></td>
</tr>
<tr class="odd">
<td></td>
</tr>
<tr class="even">
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="4"><strong>     </strong></td>
<td></td>
<td colspan="4"><strong>     </strong></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="4"><em>(Employee Signature)</em></td>
<td></td>
<td colspan="4"><em>(Date)</em></td>
<td></td>
</tr>
</tbody>
</table>

+--------+------------------------------------------------+-----------+
| *BPA F | **CERTIFICATION OF HEALTH CARE PROVIDER**      | *E        |
| 378    |                                                | lectronic |
| 0.02e* | **for Serious Health Condition**               | Form      |
|        |                                                | Approved* |
| *Page  |                                                |           |
| 3*     |                                                | *by CIEP  |
|        |                                                | --        |
| *(0    |                                                | 08        |
| 8-03)* |                                                | /08/2003* |
+--------+------------------------------------------------+-----------+
|        |                                                |           |
+--------+------------------------------------------------+-----------+
| ***S   |                                                |           |
| ERIOUS |                                                |           |
| HEALTH |                                                |           |
| CONDIT |                                                |           |
| ION*** |                                                |           |
+--------+------------------------------------------------+-----------+
| ***    |                                                |           |
| (Title |                                                |           |
| II of  |                                                |           |
| the    |                                                |           |
| Family |                                                |           |
| and    |                                                |           |
| M      |                                                |           |
| edical |                                                |           |
| Leave  |                                                |           |
| Act of |                                                |           |
| 1993   |                                                |           |
| and    |                                                |           |
| Use of |                                                |           |
| Ex     |                                                |           |
| tended |                                                |           |
| Sick   |                                                |           |
| Leave  |                                                |           |
| under  |                                                |           |
| 5 CFR  |                                                |           |
| S      |                                                |           |
| ubpart |                                                |           |
| D)***  |                                                |           |
+--------+------------------------------------------------+-----------+
|        |                                                |           |
+--------+------------------------------------------------+-----------+
| ***S   |                                                |           |
| erious |                                                |           |
| Health |                                                |           |
| Con    |                                                |           |
| dition |                                                |           |
| means  |                                                |           |
| an     |                                                |           |
| il     |                                                |           |
| lness, |                                                |           |
| i      |                                                |           |
| njury, |                                                |           |
| impai  |                                                |           |
| rment, |                                                |           |
| or     |                                                |           |
| ph     |                                                |           |
| ysical |                                                |           |
| or     |                                                |           |
| mental |                                                |           |
| con    |                                                |           |
| dition |                                                |           |
| that   |                                                |           |
| in     |                                                |           |
| volves |                                                |           |
| one of |                                                |           |
| the    |                                                |           |
| f      |                                                |           |
| ollowi |                                                |           |
| ng***: |                                                |           |
|        |                                                |           |
| **(1)  |                                                |           |
| Ho     |                                                |           |
| spital |                                                |           |
| C      |                                                |           |
| are.** |                                                |           |
| Inp    |                                                |           |
| atient |                                                |           |
| care   |                                                |           |
| *      |                                                |           |
| (i.e., |                                                |           |
| an     |                                                |           |
| ove    |                                                |           |
| rnight |                                                |           |
| stay)* |                                                |           |
| in a   |                                                |           |
| hos    |                                                |           |
| pital, |                                                |           |
| ho     |                                                |           |
| spice, |                                                |           |
| or     |                                                |           |
| resid  |                                                |           |
| ential |                                                |           |
| m      |                                                |           |
| edical |                                                |           |
| care   |                                                |           |
| fac    |                                                |           |
| ility, |                                                |           |
| inc    |                                                |           |
| luding |                                                |           |
| any    |                                                |           |
| period |                                                |           |
| of     |                                                |           |
| inca   |                                                |           |
| pacity |                                                |           |
| or     |                                                |           |
| subs   |                                                |           |
| equent |                                                |           |
| tre    |                                                |           |
| atment |                                                |           |
| in     |                                                |           |
| conn   |                                                |           |
| ection |                                                |           |
| with   |                                                |           |
| or     |                                                |           |
| cons   |                                                |           |
| equent |                                                |           |
| to     |                                                |           |
| such   |                                                |           |
| imp    |                                                |           |
| atient |                                                |           |
| care.  |                                                |           |
+--------+------------------------------------------------+-----------+
| **(2)  |                                                |           |
| A      |                                                |           |
| bsence |                                                |           |
| Plus   |                                                |           |
| Treatm |                                                |           |
| ent.** |                                                |           |
| A      |                                                |           |
| period |                                                |           |
| of     |                                                |           |
| inca   |                                                |           |
| pacity |                                                |           |
| of     |                                                |           |
| more   |                                                |           |
| than   |                                                |           |
| three  |                                                |           |
| conse  |                                                |           |
| cutive |                                                |           |
| ca     |                                                |           |
| lendar |                                                |           |
| days,  |                                                |           |
| inc    |                                                |           |
| luding |                                                |           |
| any    |                                                |           |
| subs   |                                                |           |
| equent |                                                |           |
| trea   |                                                |           |
| tment, |                                                |           |
| or     |                                                |           |
| period |                                                |           |
| of     |                                                |           |
| inca   |                                                |           |
| pacity |                                                |           |
| re     |                                                |           |
| lating |                                                |           |
| to the |                                                |           |
| same   |                                                |           |
| cond   |                                                |           |
| ition, |                                                |           |
| that   |                                                |           |
| also   |                                                |           |
| inv    |                                                |           |
| olves: |                                                |           |
|        |                                                |           |
| \(a\)  |                                                |           |
| Tre    |                                                |           |
| atment |                                                |           |
| two or |                                                |           |
| more   |                                                |           |
| times  |                                                |           |
| by a   |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| pro    |                                                |           |
| vider, |                                                |           |
| or a   |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| pr     |                                                |           |
| ovider |                                                |           |
| under  |                                                |           |
| direct |                                                |           |
| super  |                                                |           |
| vision |                                                |           |
| of the |                                                |           |
| af     |                                                |           |
| fected |                                                |           |
| indivi |                                                |           |
| dual's |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| pro    |                                                |           |
| vider, |                                                |           |
| or by  |                                                |           |
| a      |                                                |           |
| pr     |                                                |           |
| ovider |                                                |           |
| of     |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| se     |                                                |           |
| rvices |                                                |           |
| under  |                                                |           |
| orders |                                                |           |
| of, or |                                                |           |
| on     |                                                |           |
| re     |                                                |           |
| ferral |                                                |           |
| by, a  |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| pro    |                                                |           |
| vider; |                                                |           |
| or     |                                                |           |
|        |                                                |           |
| \(b\)  |                                                |           |
| Tre    |                                                |           |
| atment |                                                |           |
| by a   |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| pr     |                                                |           |
| ovider |                                                |           |
| on at  |                                                |           |
| least  |                                                |           |
| one    |                                                |           |
| oc     |                                                |           |
| casion |                                                |           |
| which  |                                                |           |
| r      |                                                |           |
| esults |                                                |           |
| in a   |                                                |           |
| r      |                                                |           |
| egimen |                                                |           |
| of     |                                                |           |
| cont   |                                                |           |
| inuing |                                                |           |
| tre    |                                                |           |
| atment |                                                |           |
| under  |                                                |           |
| the    |                                                |           |
| super  |                                                |           |
| vision |                                                |           |
| of the |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| pr     |                                                |           |
| ovider |                                                |           |
| *      |                                                |           |
| (e.g., |                                                |           |
| a      |                                                |           |
| course |                                                |           |
| of     |                                                |           |
| prescr |                                                |           |
| iption |                                                |           |
| medi   |                                                |           |
| cation |                                                |           |
| or     |                                                |           |
| t      |                                                |           |
| herapy |                                                |           |
| req    |                                                |           |
| uiring |                                                |           |
| s      |                                                |           |
| pecial |                                                |           |
| equ    |                                                |           |
| ipment |                                                |           |
| to     |                                                |           |
| r      |                                                |           |
| esolve |                                                |           |
| or     |                                                |           |
| all    |                                                |           |
| eviate |                                                |           |
| the    |                                                |           |
| health |                                                |           |
| condit |                                                |           |
| ion).* |                                                |           |
|        |                                                |           |
| **(3)  |                                                |           |
| Pre    |                                                |           |
| gnancy |                                                |           |
| or     |                                                |           |
| C      |                                                |           |
| hildbi |                                                |           |
| rth.** |                                                |           |
| Any    |                                                |           |
| period |                                                |           |
| of     |                                                |           |
| inca   |                                                |           |
| pacity |                                                |           |
| due to |                                                |           |
| pre    |                                                |           |
| gnancy |                                                |           |
| or     |                                                |           |
| child  |                                                |           |
| birth, |                                                |           |
| or for |                                                |           |
| pr     |                                                |           |
| enatal |                                                |           |
| care,  |                                                |           |
| even   |                                                |           |
| if the |                                                |           |
| af     |                                                |           |
| fected |                                                |           |
| indi   |                                                |           |
| vidual |                                                |           |
| does   |                                                |           |
| not    |                                                |           |
| r      |                                                |           |
| eceive |                                                |           |
| active |                                                |           |
| tre    |                                                |           |
| atment |                                                |           |
| from a |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| pr     |                                                |           |
| ovider |                                                |           |
| during |                                                |           |
| the    |                                                |           |
| period |                                                |           |
| of     |                                                |           |
| inca   |                                                |           |
| pacity |                                                |           |
| or the |                                                |           |
| period |                                                |           |
| of     |                                                |           |
| inca   |                                                |           |
| pacity |                                                |           |
| does   |                                                |           |
| not    |                                                |           |
| last   |                                                |           |
| more   |                                                |           |
| than 3 |                                                |           |
| conse  |                                                |           |
| cutive |                                                |           |
| ca     |                                                |           |
| lendar |                                                |           |
| days.  |                                                |           |
|        |                                                |           |
| **(4)  |                                                |           |
| C      |                                                |           |
| hronic |                                                |           |
| Condit |                                                |           |
| ions** |                                                |           |
| **Req  |                                                |           |
| uiring |                                                |           |
| T      |                                                |           |
| reatme |                                                |           |
| nts**. |                                                |           |
| A      |                                                |           |
| C      |                                                |           |
| hronic |                                                |           |
| con    |                                                |           |
| dition |                                                |           |
| which: |                                                |           |
|        |                                                |           |
| \(1\)  |                                                |           |
| Re     |                                                |           |
| quires |                                                |           |
| pe     |                                                |           |
| riodic |                                                |           |
| visits |                                                |           |
| for    |                                                |           |
| tre    |                                                |           |
| atment |                                                |           |
| by a   |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| pro    |                                                |           |
| vider, |                                                |           |
| or by  |                                                |           |
| a      |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| pr     |                                                |           |
| ovider |                                                |           |
| under  |                                                |           |
| direct |                                                |           |
| super  |                                                |           |
| vision |                                                |           |
| of the |                                                |           |
| af     |                                                |           |
| fected |                                                |           |
| indivi |                                                |           |
| dual's |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| pro    |                                                |           |
| vider. |                                                |           |
|        |                                                |           |
| \(2\)  |                                                |           |
| Con    |                                                |           |
| tinues |                                                |           |
| over   |                                                |           |
| an     |                                                |           |
| ex     |                                                |           |
| tended |                                                |           |
| period |                                                |           |
| of     |                                                |           |
| time   |                                                |           |
| *(inc  |                                                |           |
| luding |                                                |           |
| rec    |                                                |           |
| urring |                                                |           |
| ep     |                                                |           |
| isodes |                                                |           |
| of a   |                                                |           |
| single |                                                |           |
| unde   |                                                |           |
| rlying |                                                |           |
| condit |                                                |           |
| ion);* |                                                |           |
| and    |                                                |           |
|        |                                                |           |
| \(3\)  |                                                |           |
| May    |                                                |           |
| cause  |                                                |           |
| ep     |                                                |           |
| isodic |                                                |           |
| rather |                                                |           |
| than a |                                                |           |
| cont   |                                                |           |
| inuing |                                                |           |
| period |                                                |           |
| of     |                                                |           |
| inca   |                                                |           |
| pacity |                                                |           |
| *      |                                                |           |
| (e.g., |                                                |           |
| a      |                                                |           |
| sthma, |                                                |           |
| dia    |                                                |           |
| betes, |                                                |           |
| epi    |                                                |           |
| lepsy, |                                                |           |
| e      |                                                |           |
| tc.).* |                                                |           |
| The    |                                                |           |
| con    |                                                |           |
| dition |                                                |           |
| is     |                                                |           |
| c      |                                                |           |
| overed |                                                |           |
| even   |                                                |           |
| if the |                                                |           |
| af     |                                                |           |
| fected |                                                |           |
| indi   |                                                |           |
| vidual |                                                |           |
| does   |                                                |           |
| not    |                                                |           |
| r      |                                                |           |
| eceive |                                                |           |
| active |                                                |           |
| tre    |                                                |           |
| atment |                                                |           |
| from a |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| pr     |                                                |           |
| ovider |                                                |           |
| during |                                                |           |
| the    |                                                |           |
| period |                                                |           |
| of     |                                                |           |
| inca   |                                                |           |
| pacity |                                                |           |
| or the |                                                |           |
| period |                                                |           |
| of     |                                                |           |
| inca   |                                                |           |
| pacity |                                                |           |
| does   |                                                |           |
| not    |                                                |           |
| last   |                                                |           |
| more   |                                                |           |
| than 3 |                                                |           |
| conse  |                                                |           |
| cutive |                                                |           |
| ca     |                                                |           |
| lendar |                                                |           |
| days.  |                                                |           |
|        |                                                |           |
| **(5)  |                                                |           |
| P      |                                                |           |
| ermane |                                                |           |
| nt/Lon |                                                |           |
| g-term |                                                |           |
| cond   |                                                |           |
| itions |                                                |           |
| Req    |                                                |           |
| uiring |                                                |           |
| Su     |                                                |           |
| pervis |                                                |           |
| ion**. |                                                |           |
| A      |                                                |           |
| period |                                                |           |
| of     |                                                |           |
| inca   |                                                |           |
| pacity |                                                |           |
| that   |                                                |           |
| is     |                                                |           |
| per    |                                                |           |
| manent |                                                |           |
| or     |                                                |           |
| lon    |                                                |           |
| g-term |                                                |           |
| due to |                                                |           |
| a      |                                                |           |
| con    |                                                |           |
| dition |                                                |           |
| for    |                                                |           |
| which  |                                                |           |
| tre    |                                                |           |
| atment |                                                |           |
| may    |                                                |           |
| not be |                                                |           |
| effe   |                                                |           |
| ctive. |                                                |           |
| The    |                                                |           |
| af     |                                                |           |
| fected |                                                |           |
| indi   |                                                |           |
| vidual |                                                |           |
| must   |                                                |           |
| be     |                                                |           |
| under  |                                                |           |
| the    |                                                |           |
| cont   |                                                |           |
| inuing |                                                |           |
| super  |                                                |           |
| vision |                                                |           |
| of,    |                                                |           |
| but    |                                                |           |
| need   |                                                |           |
| not be |                                                |           |
| rec    |                                                |           |
| eiving |                                                |           |
| active |                                                |           |
| tre    |                                                |           |
| atment |                                                |           |
| by, a  |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| pr     |                                                |           |
| ovider |                                                |           |
| *      |                                                |           |
| (e.g., |                                                |           |
| Alzhei |                                                |           |
| mer's, |                                                |           |
| severe |                                                |           |
| s      |                                                |           |
| troke, |                                                |           |
| or     |                                                |           |
| te     |                                                |           |
| rminal |                                                |           |
| stages |                                                |           |
| of a   |                                                |           |
| dise   |                                                |           |
| ase).* |                                                |           |
|        |                                                |           |
| **(6)  |                                                |           |
| Mu     |                                                |           |
| ltiple |                                                |           |
| Trea   |                                                |           |
| tments |                                                |           |
| *      |                                                |           |
| (Non-C |                                                |           |
| hronic |                                                |           |
| Con    |                                                |           |
| dition |                                                |           |
| s).*** |                                                |           |
| Any    |                                                |           |
| period |                                                |           |
| of     |                                                |           |
| a      |                                                |           |
| bsence |                                                |           |
| to     |                                                |           |
| r      |                                                |           |
| eceive |                                                |           |
| mu     |                                                |           |
| ltiple |                                                |           |
| trea   |                                                |           |
| tments |                                                |           |
| *(inc  |                                                |           |
| luding |                                                |           |
| any    |                                                |           |
| period |                                                |           |
| of*    |                                                |           |
| *reco  |                                                |           |
| very)* |                                                |           |
| by a   |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| pr     |                                                |           |
| ovider |                                                |           |
| or by  |                                                |           |
| a      |                                                |           |
| pr     |                                                |           |
| ovider |                                                |           |
| of     |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| se     |                                                |           |
| rvices |                                                |           |
| under  |                                                |           |
| orders |                                                |           |
| of, or |                                                |           |
| on     |                                                |           |
| re     |                                                |           |
| ferral |                                                |           |
| by, a  |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| pro    |                                                |           |
| vider, |                                                |           |
| either |                                                |           |
| for    |                                                |           |
| resto  |                                                |           |
| rative |                                                |           |
| s      |                                                |           |
| urgery |                                                |           |
| after  |                                                |           |
| an     |                                                |           |
| ac     |                                                |           |
| cident |                                                |           |
| or     |                                                |           |
| other  |                                                |           |
| injury |                                                |           |
| or for |                                                |           |
| a      |                                                |           |
| con    |                                                |           |
| dition |                                                |           |
| that   |                                                |           |
| would  |                                                |           |
| likely |                                                |           |
| result |                                                |           |
| in a   |                                                |           |
| period |                                                |           |
| of     |                                                |           |
| inca   |                                                |           |
| pacity |                                                |           |
| of     |                                                |           |
| more   |                                                |           |
| than 3 |                                                |           |
| conse  |                                                |           |
| cutive |                                                |           |
| ca     |                                                |           |
| lendar |                                                |           |
| days   |                                                |           |
| in the |                                                |           |
| a      |                                                |           |
| bsence |                                                |           |
| of     |                                                |           |
| m      |                                                |           |
| edical |                                                |           |
| interv |                                                |           |
| ention |                                                |           |
| or     |                                                |           |
| tre    |                                                |           |
| atment |                                                |           |
| *      |                                                |           |
| (e.g., |                                                |           |
| chem   |                                                |           |
| othera |                                                |           |
| py/rad |                                                |           |
| iation |                                                |           |
| for    |                                                |           |
| c      |                                                |           |
| ancer, |                                                |           |
| ph     |                                                |           |
| ysical |                                                |           |
| t      |                                                |           |
| herapy |                                                |           |
| for    |                                                |           |
| severe |                                                |           |
| arth   |                                                |           |
| ritis, |                                                |           |
| di     |                                                |           |
| alysis |                                                |           |
| for    |                                                |           |
| kidney |                                                |           |
| dise   |                                                |           |
| ase).* |                                                |           |
+--------+------------------------------------------------+-----------+
| ***S   |                                                |           |
| erious |                                                |           |
| health |                                                |           |
| con    |                                                |           |
| dition |                                                |           |
| does   |                                                |           |
| not    |                                                |           |
| incl   |                                                |           |
| ude*** |                                                |           |
| r      |                                                |           |
| outine |                                                |           |
| phy    |                                                |           |
| sical, |                                                |           |
| eye,   |                                                |           |
| or     |                                                |           |
| dental |                                                |           |
| e      |                                                |           |
| xamina |                                                |           |
| tions; |                                                |           |
| a      |                                                |           |
| r      |                                                |           |
| egimen |                                                |           |
| of     |                                                |           |
| cont   |                                                |           |
| inuing |                                                |           |
| tre    |                                                |           |
| atment |                                                |           |
| that   |                                                |           |
| in     |                                                |           |
| cludes |                                                |           |
| the    |                                                |           |
| taking |                                                |           |
| of     |                                                |           |
| over   |                                                |           |
| -the-c |                                                |           |
| ounter |                                                |           |
| medica |                                                |           |
| tions, |                                                |           |
| bed    |                                                |           |
| -rest, |                                                |           |
| exe    |                                                |           |
| rcise, |                                                |           |
| and    |                                                |           |
| other  |                                                |           |
| s      |                                                |           |
| imilar |                                                |           |
| acti   |                                                |           |
| vities |                                                |           |
| that   |                                                |           |
| can be |                                                |           |
| ini    |                                                |           |
| tiated |                                                |           |
| w      |                                                |           |
| ithout |                                                |           |
| a      |                                                |           |
| visit  |                                                |           |
| to the |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| pro    |                                                |           |
| vider, |                                                |           |
| a      |                                                |           |
| con    |                                                |           |
| dition |                                                |           |
| for    |                                                |           |
| which  |                                                |           |
| co     |                                                |           |
| smetic |                                                |           |
| trea   |                                                |           |
| tments |                                                |           |
| are    |                                                |           |
| a      |                                                |           |
| dminis |                                                |           |
| tered, |                                                |           |
| unless |                                                |           |
| inp    |                                                |           |
| atient |                                                |           |
| ho     |                                                |           |
| spital |                                                |           |
| care   |                                                |           |
| is     |                                                |           |
| re     |                                                |           |
| quired |                                                |           |
| or     |                                                |           |
| unless |                                                |           |
| c      |                                                |           |
| omplic |                                                |           |
| ations |                                                |           |
| de     |                                                |           |
| velop; |                                                |           |
| or an  |                                                |           |
| a      |                                                |           |
| bsence |                                                |           |
| b      |                                                |           |
| ecause |                                                |           |
| of an  |                                                |           |
| empl   |                                                |           |
| oyee's |                                                |           |
| use of |                                                |           |
| an     |                                                |           |
| i      |                                                |           |
| llegal |                                                |           |
| subs   |                                                |           |
| tance, |                                                |           |
| unless |                                                |           |
| the    |                                                |           |
| em     |                                                |           |
| ployee |                                                |           |
| is     |                                                |           |
| rec    |                                                |           |
| eiving |                                                |           |
| tre    |                                                |           |
| atment |                                                |           |
| for    |                                                |           |
| sub    |                                                |           |
| stance |                                                |           |
| abuse  |                                                |           |
| by a   |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| pro    |                                                |           |
| vider, |                                                |           |
| or by  |                                                |           |
| a      |                                                |           |
| pr     |                                                |           |
| ovider |                                                |           |
| of     |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| se     |                                                |           |
| rvices |                                                |           |
| on     |                                                |           |
| re     |                                                |           |
| ferral |                                                |           |
| by a   |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| pro    |                                                |           |
| vider. |                                                |           |
| Ordin  |                                                |           |
| arily, |                                                |           |
| unless |                                                |           |
| c      |                                                |           |
| omplic |                                                |           |
| ations |                                                |           |
| arise, |                                                |           |
| the    |                                                |           |
| common |                                                |           |
| cold,  |                                                |           |
| the    |                                                |           |
| flu,   |                                                |           |
| ear    |                                                |           |
| aches, |                                                |           |
| upset  |                                                |           |
| st     |                                                |           |
| omach, |                                                |           |
| minor  |                                                |           |
| u      |                                                |           |
| lcers, |                                                |           |
| head   |                                                |           |
| aches, |                                                |           |
| r      |                                                |           |
| outine |                                                |           |
| dental |                                                |           |
| or     |                                                |           |
| ortho  |                                                |           |
| dontia |                                                |           |
| pro    |                                                |           |
| blems, |                                                |           |
| or     |                                                |           |
| perio  |                                                |           |
| dontal |                                                |           |
| d      |                                                |           |
| isease |                                                |           |
| are    |                                                |           |
| ex     |                                                |           |
| amples |                                                |           |
| of     |                                                |           |
| cond   |                                                |           |
| itions |                                                |           |
| that   |                                                |           |
| do not |                                                |           |
| meet   |                                                |           |
| the    |                                                |           |
| defi   |                                                |           |
| nition |                                                |           |
| of a   |                                                |           |
| s      |                                                |           |
| erious |                                                |           |
| health |                                                |           |
| con    |                                                |           |
| dition |                                                |           |
| and do |                                                |           |
| not    |                                                |           |
| q      |                                                |           |
| ualify |                                                |           |
| for    |                                                |           |
| FMLA   |                                                |           |
| leave. |                                                |           |
| Alle   |                                                |           |
| rgies, |                                                |           |
| mi     |                                                |           |
| graine |                                                |           |
| head   |                                                |           |
| aches, |                                                |           |
| resto  |                                                |           |
| rative |                                                |           |
| dental |                                                |           |
| or     |                                                |           |
| p      |                                                |           |
| lastic |                                                |           |
| s      |                                                |           |
| urgery |                                                |           |
| after  |                                                |           |
| an     |                                                |           |
| i      |                                                |           |
| njury, |                                                |           |
| r      |                                                |           |
| emoval |                                                |           |
| of a   |                                                |           |
| can    |                                                |           |
| cerous |                                                |           |
| g      |                                                |           |
| rowth, |                                                |           |
| or     |                                                |           |
| mental |                                                |           |
| i      |                                                |           |
| llness |                                                |           |
| res    |                                                |           |
| ulting |                                                |           |
| from   |                                                |           |
| stress |                                                |           |
| may be |                                                |           |
| s      |                                                |           |
| erious |                                                |           |
| health |                                                |           |
| condi  |                                                |           |
| tions, |                                                |           |
| but    |                                                |           |
| only   |                                                |           |
| if     |                                                |           |
| such   |                                                |           |
| cond   |                                                |           |
| itions |                                                |           |
| r      |                                                |           |
| equire |                                                |           |
| inp    |                                                |           |
| atient |                                                |           |
| care   |                                                |           |
| or     |                                                |           |
| cont   |                                                |           |
| inuing |                                                |           |
| tre    |                                                |           |
| atment |                                                |           |
| by a   |                                                |           |
| health |                                                |           |
| care   |                                                |           |
| pro    |                                                |           |
| vider. |                                                |           |
+--------+------------------------------------------------+-----------+