FAMILY MEDICAL LEAVE- YOUR SERIOUS HEALTH CONDITION ACTION ITEMS & INFO

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1 Complete the following action items for a successful continuous or intermittent Family Medical Leave (FML). Action items for intermittent FML follow the continuous FML/Leave of Absence section. Continuous Family Medical Leave/Leave of Absence Before FML/Leave of Absence Call CIGNA to report your claim at *. Review the Leave of Absence (LOA) Policy HR 29 and the material included in this packet. Talk with your manager about your Family Medical Leave and return the completed FML/LOA Information Form to him/her (included in this packet). Provide the U.S. Department of Labor Certification of Health Care Provider form to your healthcare provider (included in this packet). Fax completed certification to CIGNA at (fax coversheet included)*. Register for MARS Home Access from the Houston Methodist network, go to the Houston Methodist Intranet and click on MARS Home Access. Login with your Houston Methodist Network ID and password. Answer 5 security questions and click Update. Contact HR Employee Transportation at AskParking@houstonmethodist.org or to cancel your parking or commuter election. Deductions will continue until you cancel. During FML/Leave of Absence Call CIGNA at and your manager to let them know you have begun Family Medical Leave Stay in-touch with your CIGNA Leave Manager to ensure he/she has everything they need from you or your physician to support your claim. Call your manager on a weekly basis (or as arranged) regarding your current return to work status. Report address and phone number changes to HR Benefits and CIGNA to ensure that you will receive benefit communications. Pay your bi-weekly benefit premiums by: o During your Leave of Absence you will be paid from your available PTO Balance. Contact HR Benefits at or hrbenefits@houstonmethodist.org for premiums to come out of your check. o If you do not have any PTO available, pay your bi-weekly benefit premiums via the Online Benefit Payment System instructions and amounts due will be ed and mailed to you after missing 2 to 3 pay periods of deductions (four to six weeks). After FML/Leave of Absence Follow your entity s return to work/clearance process. Contact your HR Generalist for more information. Call CIGNA at to report your return to work. Intermittent Family Medical Leave Before Intermittent Family Medical Leave Call CIGNA to report your claim at *. Review the Leave of Absence (LOA) Policy HR 29 and the material included in this packet. FAMILY MEDICAL LEAVE- YOUR SERIOUS HEALTH CONDITION ACTION ITEMS & INFO NAVIGATING YOUR JOURNEY Talk with your manager about your Family Medical Leave and return the completed FML/LOA Information Form to him/her (included in this packet). Provide the U.S. Department of Labor Certification of Health Care Provider form to your healthcare provider (included in this packet). Information Continued on Next Page

2 Before Intermittent Family Medical Leave (continued) Fax completed certification to CIGNA at (fax coversheet included)*. During Intermittent Family Medical Leave Report each absence to your manager in accordance with your department s call in procedure. Advise your manager that the absence is related to your Intermittent FML. Report all Intermittent FML absences to CIGNA within 24 hours. After Intermittent Family Medical Leave Re-Certify if you still need to be out on an intermittent basis and complete the action items in the Before and During Intermittent Family Medical Leave sections. Houston Methodist HR Benefits hrbenefits@houstonmethodist.org myhr.houstonmethodist.org *You must call CIGNA first before faxing any paperwork. Additionally, be advised that there may be other steps you need to take during the entire FML/LOA process to avoid missing deadlines and to ensure that you receive all benefits to which you are entitled.

3 Family Medical Leave (FML) and/or Leave of Absence (LOA) Information Form (Employee to complete and return to Manager) Employee Information (Please Print) Name Last First MI Employee ID Number Cell Phone Home Phone ( ) ( ) First Date Absent: Anticipated Return to Work Date: Basic FML Entitlement and Employee Responsibilities Eligible employees are entitled under the Family and Medical Leave Act (FMLA) to up to 12 weeks of unpaid, job-protected leave for certain family and medical reasons (480 hours if used intermittently). Submit this request form to your supervisor at least 30 days before the leave is to commence, when foreseeable. When submission of the request 30 days in advance is not foreseeable, submit the request as early as possible. The employer reserves the right to deny or postpone leave for failure to give appropriate notice when such denial/postponement would be permitted under federal law. Reason for Leave Birth* (Expected delivery date) Adoption/Foster Care/Baby Bonding* Personal Serious Health Condition Continuous Leave* Personal Serious Health Condition Intermittent Leave* Family Member Serious Health Condition Continuous Leave* Family Military Leave - Qualifying Exigency* (provide detail below) Relationship: If family member is a child, provide age: Family Member Serious Health Condition Intermittent Leave* Relationship: Relationship: Family Military Leave - Service Member Medical Care* Relationship: If family member is a child, provide age: * Contact CIGNA at to call in your LOA and to obtain information on any required actions for your LOA to be approved. Employee Acknowledgement I understand that: A Leave of Absence request for illness or injury is a medical leave of absence and must be supported with a completed Certification of Healthcare Provider form. A Short Term Disability claim must be filed for my own illness or injury if eligible. Failure to return to work at the end of an authorized leave will result in termination of employment, unless I have a reason acceptable to Houston Methodist for my inability to return. A good faith effort will be made to reinstate any employee who wishes to return from a Leave of Absence. However, reemployment is not guaranteed (FMLA and Military LOA are exceptions). During my continuous Leave of Absence, I understand that: I am to call my manager weekly or as arranged about my current return to work status. I will not accrue PTO and am not eligible for any paid holidays. My benefits will continue at the active employee rate based on my timely payment of applicable premiums (I will receive information on the amount and how to pay after I have missed two pay periods of deductions). During my intermittent Family Medical Leave, I understand that: I am to report each absence to my manager in accordance with my department s call in procedure. I am to advise my manager that the absence is related to my Intermittent FML. I must also report all Intermittent FML absences to CIGNA within 24 hours. Employee Signature Date 5/23/2017 Completed form should be maintained in departmental file.

4 Cigna Leave Solutions Certification of Health Care Provider for Employee s Serious Health Condition Date Prepared: Must Be Returned By: Employee Name: Employer Name: Leave ID: Reason for requesting leave: Leave date(s)/period(s) requested: SECTION I: For Completion by the EMPLOYEE INSTRUCTIONS to the EMPLOYEE: Please complete Section I before giving this form to your medical provider. The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to your own serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections. 29 U.S.C. 2613, 2614(c)(3). Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA request. 29 C.F.R Your employer must give you at least 15 calendar days to return this form. 29 C.F.R (b). If your certification is returned incomplete or insufficient, your employer must give you at least 7 calendar days to cure any deficiency. 29 C.F.R (c). The Genetic Information Nondiscrimination Act of 2008 (GINA), and, where applicable, the California Genetic Information Nondiscrimination Act of 2011 (CalGINA), prohibits employers and other entities covered by GINA Title II, and where applicable CalGINA, from requesting or requiring genetic information of employees or their family members, except as specifically allowed by law. In order to comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information, unless failing to provide the information will result in an incomplete or insufficient certification. (If the employee is seeking leave under the District of Columbia Family and Medical Leave Act, genetic information should not be provided under any circumstance.) Genetic information, as defined by GINA, includes an individual s family medical history, the results of an individual s or family member s genetic tests, the fact that an individual or an individual s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. Genetic Information, as defined by CalGINA, includes information about the individual s or the individual's family member's genetic tests, information regarding the manifestation of a disease or disorder in a family member of the individual, and includes information from genetic services or participation in clinical research that includes genetic services by an individual or any family member of the individual. Genetic Information does not include information about an individual s sex or age. *PLEASE BE SURE TO RETURN ALL PAGES Employee Job Title: Regular Work Schedule: Employee Signature Date See reverse to provide additional information Cigna Leave Solutions Fax: FMLACertifications@Cigna.com Page 1 of 5

5 SECTION II: For Completion by the HEALTH CARE PROVIDER INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA. Answer, fully and completely, all applicable parts. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Be as specific as you can; terms such as lifetime, unknown, or indeterminate may not be sufficient to determine FMLA coverage. Limit your responses to the condition for which the employee is seeking leave. Please be sure to sign the form on the last page. Subsection A: Must be completed for ALL types of leaves: 1. Provider s name: Phone # Fax # Address: Type of practice / Medical specialty: Please complete the following: 2. Approximate date condition commenced: Probable Duration of condition: 3. Date(s) you treated the patient for condition in the past 12 months: 4. Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility? No Yes If yes, dates of admission in the past 12 months: 5. Will the patient need treatment visits at least twice per year due to the condition? No Yes 6. Was medication, other than over-the-counter medication, prescribed? No Yes 7. Is the medical condition pregnancy? No Yes, If yes, expected delivery date: 8. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job functions? No Yes: If yes, explain 9. Is the employee unable to perform any of his/her job functions due to the condition based on the employee s own description of his/her job? No Yes: If yes, identify the job functions the employee is unable to perform: 10. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such medical facts may include symptoms, diagnosis, including x-rays or diagnostic testing, or any regimen of continuing treatment such as the use of specialized equipment) (Note: If the employee is requesting leave under the California Family Rights Act or the Connecticut Family and Medical Leave Act, do not include diagnosis information): Subsection B: Must be completed for all CONTINUOUS LEAVES: 1. Will the employee be incapacitated for a single continuous period of time due to his/her medical condition, including any time for treatment and recover? No Yes If yes, estimate the beginning and ending dates for the period of incapacity: Start Date End Date (Form is considered incomplete/insufficient if not provided for a continuous leave) Cigna Leave Solutions Fax: FMLACertifications@Cigna.com Page 2 of 5

6 Subsection C: Must be completed for all REDUCED SCHEDULED LEAVES: 1. Is it medically necessary for the employee to work part-time or a reduced schedule because of the employee s condition? (this includes follow up treatment appointments) No Yes If yes, estimate the part-time or reduced work schedule the employee needs: hour(s) per day time(s) per week time(s) per month Start Date End Date (Form is considered incomplete/insufficient if not provided for a reduced/part-time leave) Subsection D: Must be completed for all INTERMITTENT LEAVES. 1. Will the employee need intermittent time off, No Yes: if yes, estimate the beginning and ending dates for the period the patient needs to be out of work: Start Date End Date 2. OFFICE VISITS/TREATMENTS: Based upon the patient s medical history and your knowledge of the medical condition, estimate the maximum frequency of follow-up treatments/office visits that employee would need off work for related incapacity that the employee may experience over the next 6 months. (e.g., Duration: 3 hours per visit/treatment Frequency: 3 times per 1 week(s) / month(s) (circle one)) Duration: hours per visit/treatment Frequency: times per week(s) / month(s) (circle one) (Form is considered incomplete/insufficient if not provided for an intermittent leave) 3. INCAPACITY: Based upon the patient s medical history and your knowledge of the medical condition, estimate the maximum frequency of incapacity that employee would need off work over the next 6 months. (e.g., Duration: 3 hours per day or 2 days per episode Frequency: 3 times per 1 week(s) / month(s) (circle one)) Duration: hours per day or days per episode Frequency: times per week(s) / month(s) (circle one) (Form is considered incomplete/insufficient if not provided for an intermittent leave) ADDITIONAL INFORMATION: Signature of Health Care Provider Date PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. 2616; 29 C.F.R The U.S. Department of Labor estimates that it will take an average of 20 minutes for respondents to complete this collection of information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution AV, NW, Washington, DC DO NOT SEND THE COMPLETED FORM TO THE WAGE AND HOUR DIVISION. Cigna Leave Solutions Fax: FMLACertifications@Cigna.com Page 3 of 5

7 Cigna Leave Solutions Fax: Page 4 of 5

8 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION NOTE: This authorization is designed to comply with HIPAA and relates to information necessary to administer coverage and services under your employer s employee health and welfare plan(s) ("the Plan") and similar or coordinating governmental benefits. COMPLETING THIS AUTHORIZATION IS NOT REQUIRED FOR LEAVE UNDER THE FAMILY AND MEDICAL LEAVE ACT, OR STATE LEAVES OR COMPANY LEAVE PLANS ADMINISTERED BY CIGNA LEAVE SOLUTIONS. HOWEVER, IF YOU FAIL TO PROVIDE A VALID AND COMPLETE CERTIFICATION AND DO NOT AUTHORIZE CIGNA LEAVE SOLUTIONS, WHETHER USING THIS AUTHORIZATION OR ANOTHER VALID AUTHORIZATION, TO CONTACT YOUR HEALTH CARE PROVIDER, YOUR LEAVE MAY BE DENIED. I, NameFull, EmployeeNumber,employed at ClientName, hereby authorize the use or disclosure of my health information as described in this authorization. I authorize representatives of Life Insurance Company of North America, which does business as Cigna Leave Solutions, to contact the health care provider who filled out this form to obtain medical information required for completion of this form and/or to clarify or validate medical information that was provided on this form. I understand such medical information will be obtained as permitted under the Family and Medical Leave Act (FMLA) and be limited only to what is required to assess my eligibility for leave under the FMLA. I also understand such information may be used to determine my eligibility for approval of leave, or for consideration of other leaves associated with my leave request, including applicable state family and medical leave laws and/or other leaves of absence administered by Cigna Leave Solutions. I understand that, although limited to the reason for which I am requesting leave, information about my health may relate to any disorder of the immune system including, but not limited to HIV and AIDS; use of drugs and alcohol; and mental and physical history, condition, advice or treatment, but does not include psychotherapy notes. [If my [employer, union, group association] sponsors any other plans, whether or not underwritten or administered by Life Insurance Company of North America, or its affiliates, the information and/or records obtained may also be shared with the underwriting company [insurer] or administrators of those other plans, including their internal or external health management, disease management, wellness, employee/member assistance program or other similar programs, for the purpose of administering any service, benefit or feature described in those plans.] I agree to the terms of this authorization and understand that the use and further disclosure of information disclosed hereunder may no longer be subject to protection under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, though it may still be protected under other applicable privacy laws. For any leave request, this authorization is valid for the shorter of 6 months or the duration of my leave. I am entitled to a copy of this authorization and a photographic or electronic copy of it is as valid as the original. I understand that I have the right to revoke this authorization at any time by notifying Cigna Leave Solutions in writing. I understand that the revocation is only effective after it is received and documented in Cigna Leave Solutions leave management system. I understand that any use or disclosure made prior to the revocation under this authorization will not be affected by a revocation. I understand that after this information is disclosed, federal law might not protect it and the recipient might re-disclose it. Signature of Employee Date Signed Print Name If a Personal Representative executes this form, that Representative warrants that he or she has authority to sign this form on the basis of: Cigna Leave Solutions Fax: FMLACertifications@Cigna.com Page 5 of 5

9 Houston Methodist 6565 Fannin, GB 164 Houston, Texas houstonmethodist.org TO: CIGNA INSURANCE FROM: FAX NUMBER: PHONE NUMBER: RE: New LOA/FML Claim DATE: ****CONFIDENTIALITY NOTICE**** This facsimile transmission, including attachments to this cover page, is the property of Houston Methodist and/or its relevant affiliates and may contain confidential and privileged material for the sole use of the intended recipient(s). Any review, use, distribution, or disclosure by others is strictly prohibited. If you are not the intended recipient (or are not authorized to receive for the recipient), please contact the sender or reply to Houston Methodist at and return all copies of the facsimile to Houston Methodist. The sender or can provide you with mailing instructions. Otherwise, this facsimile may be destroyed using a cross-shredder. 1