New York City District Council of Carpenters
Apprentice Medical Leave Policy
Certification of Health Care Provider
(Return this form to the Patient)
(1)______ (2)______ (3)______ (4)______ (5)______ (6)______ None of the above
If yes, give the probable duration:
If the patient will be absent from work, school or other daily activities because of treatment on an intermittent or part-time basis, also provide an estimate of the probable number of and interval between such treatments, actual or estimated dates of treatment if known and period required for recovery if any:
Signature of Health Care Provider
Type of Practice:________________________________
A “Serious Health Condition” means an illness, injury impairment, or physical or mental condition that involves one of the following:
Inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential medical care facility, including any period of incapacity2 or subsequent treatment in connection with or consequent to such inpatient care.
(a) A period of incapacity2 of more than three calendar days (including any subsequent treatment or period of incapacity relating to the same condition), that also involves”
(1) Treatment two or more times by a health care provider, by a nurse or physician’s assistant under direct supervision of a health care provider, or by a provider of health care services (e.g., physical therapist) under orders of, or on referral by, a health care provider; or
(2) Treatment by a health care provider on at least one occasion which results in a regimen of continuing treatment under the supervision of a health care provider.
Any period of incapacity due to pregnancy or for prenatal care.
A chronic condition which:
(1) Requires periodic visits for treatment by a health care provider, or by a nurse or physician’s assistant under direct supervision of a health care provider.
(2) Continues over an extended period of time (including recurring episodes of a single underlying condition); and
(3) May cause episodic rather than a continuing period of incapacity2 (e.g., asthma, diabetes, epilepsy, etc.)
A period of incapacity2 which is permanent or long-term due to a condition for which treatment may not be effective. The employee or family member must be under the continuing supervision of, but need not be receiving active treatment by a health care provider. Examples include Alzheimer’s, a severe stroke, or the terminal stages of a disease.
Any period of absence to receive multiple treatments (including any period of recovery therefrom) by a health care provider or by a provider of health care services under orders of, or on referral by, a health care provider, either for restorative surgery after an accident or other injury, or for a condition that would likely result in a period of Incapacity of more than three consecutive calendar days in the absence of medical intervention or treatment such as cancer (chemotherapy, radiation, etc.), severs arthritis (physical therapy), and kidney disease (dialysis).
NEW YORK CITY DISTRICT COUNCIL OF CARPENTERS WELFARE FUND
For Use of Disclosure of Protected Health Information
|PURPOSE OF THIS FORM|
Under the Health Insurance Portability & Accountability Act (HIPAA), in order for the Welfare Fund to use or disclose Protected Health Information to someone other than you, you must complete this Authorization Form and return it to the Fund.
Protected Health Information “PHI” is information that is created, received, transmitted or stored by the Fund which relates to your past, present, or future physical or mental health, health care, or payment for health care, and either identifies you or provides a reasonable basis for identifying you. Except as permitted by law, the Fund may not use or disclose PHI to persons other than those you specify on this form.
The Fund may request that you complete this form where the use of disclosure of information is necessary to carry out functions of the Fund. In addition, you may submit this form to the Fund because you want someone to request or receive your PHI from the Fund. This form is not needed if you are requesting your own PHI from the Fund.
Name: _______________________________________ UBC#_____________________________________
I hereby give permission to the Welfare Fund, or any of its affiliates or agents and their staff performing services in connection with my claim for health plan benefits, to disclose my protected health information (PHI) identified in Section #3 of this Form to the following class persons:
Employer or the Fund New York City District Council of Carpenters Pension Fund______________________
Business Manager, Union Official or Agent_____________________________________________________
Other Person(s) New York County Health Services Review Organization/Med Review___________________
I authorize the Welfare Fund to disclose PHI (including written, electronic, or oral information) to the person(s) identified in Section #2 of this form in connection with (mark all that apply): (if you want different people to have access to different information, you must fill out separate forms.)
__ Hospital/Medical Claims __ Prescription Drug Claims __Vision Claims
__ Mental Health Claims __ Dental Claims __ Hearing Aid Claims
__ Specific claim for health benefits __ Disability Claim information __ Work/Eligibility History
(Describe the event or claims involved with the date of service)
The purpose of the use of disclosure of my protected health information (PHI) is:
NOTE: “at the request of the individual” is a sufficient description of the purpose.
This Authorization form is valid until:
I understand that:
Your Signature (or Signature of Personal Representative*) Date
*If you are acting as the personal representative of the individual whose PHI is to be disclosed, you must provide proof of your authority to act for that individual.
 Here and elsewhere on this form, the information sought relates only to the condition for which the patient is taking leave.
 “Incapacity,” for purposes of leave is defined to mean inability to work, attend school or perform other regular daily activities due to the serious health condition, treatment therefore, or recovery therefrom.
 Treatment includes examinations to determine if a serious health condition exists and evaluations of the condition. Treatment does not include routine physical examinations, eye examinations, or dental examinations.
 A regimen of continuing treatment includes, for example, a course of prescription medication (e.g., an antibiotic) or therapy requiring special equipment to resolve or alleviate the health condition. A regimen of treatment does not include the taking of over-the-counter medications such as aspirin, antihistamines, or salves; or bed-rest, drinking fluids, exercise, and other similar activities that can be initiated without a visit to a health care provider.
Please enter your UBC number and your password below