Disability Claim/Family Medical

Leave Attending Physician’s Certification

The Lincoln National Life Insurance Company

PO Box 2786
Omaha NE 68103-2786
Toll free (800) 423-2765
Toll free Fax (855) 831-7061
www.LincolnFinancial.com

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. § 825.313. Your employer must give you at least 15 calendar days to return this form.
29 C.F.R. § 825.305(b).
Questions marked with * are required for purposes of considering your disability claim. Failure to provide answers to such
questions may impact your disability decision, but are not required to make a decision on your FMLA entitlement.

Employee’s Name:______________________________________________________________________________________
*Employee’s SSN:_______________________________________________________________________________________
Employer’s Name:_______________________________________________________________________________________
Employee’s Job Title:_____________________________________________________________________________________

Employee Acknowledgement: By placing my signature below I acknowledge and certify that all information submitted on this
form and that I provided when requesting my leave is true and correct. I have not made and will not make alterations to the
Health Care Provider’s Statement. I understand that it is my responsibility to return this completed statement with the Health
Care Provider’s certification and any clarifying, missing, or incomplete information later requested by The Lincoln National Life
Insurance Company, within the specified timelines. I understand failure to provide a timely, complete, and sufficient certification
may result in a denial of my Disability Claim and/or Family Medical Leave request.

________________________________________________________________ ________________________________
Signature of Employee Date

SECTION II: For Completion by the HEALTH CARE PROVIDER

INSTRUCTIONS to the Health Care Provider: Your patient has requested leave under the FMLA and their employer’s disability
Plan or Policy. Answer, fully and completely, all applicable parts. The questions marked with * are required for purposes of
considering your patient’s entitlement to these disability benefits. 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 coverage under the FMLA or the disability Plan or Policy. Limit your responses to the condition for which
the employee is seeking leave. Please be sure to sign the form on the last page.

Provider’s Name and Business Address:_____________________________________________________________________

Type of Practice/Medical Specialty:__________________________________________________________________________

Telephone: (____) ______________________________________ Fax:(____) _______________________________________

Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 1 of 5
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GINA Important Notice: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities
covered by GINA Title II from requesting or requiring genetic information of employees or their family members. 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.
“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.

PART A: Medical Facts and Treatment

1. Approximate date condition commenced:__________________________________________________________________

2. Probable duration of condition:__________________________________________________________________________

3. *Date employee was unable to work because of a disability:___________________________________________________

Mark below as applicable:

4. *Describe the relevant facts related to the condition(s) for which the employee is seeking FMLA leave and/or disability benefits:

*Height:______________________________

*Weight:______________________________

*Blood Pressure: ______________________

*Diagnosis (including complications and comorbidities):_____________________________________________________________

__________________________________________________________________________________________________

*Objective findings (Including current x-rays, EKG’s, laboratory data and any clinical findings):____________________________________

__________________________________________________________________________________________________

5. *Do you consider this condition to be due to your patient’s employment? h Yes h No

6. *Describe the nature of treatment:_______________________________________________________________________

__________________________________________________________________________________________________

Has surgery been scheduled or performed? h Yes h No If “Yes” date of surgery:________________________________

Type of surgery scheduled:_____________________________________________________________________________

Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility? h Yes h No
If “Yes”, dates of admission: ____________________________________________________________________________

Date(s) you treated the patient for condition:________________________________________________________________

Will the patient need to have treatment visits at least twice per year due to the condition? h Yes h No
Was medication, other than over-the-counter medication, prescribed? h Yes h No
If “Yes”, please list:___________________________________________________________________________________

Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)? h Yes h No
If “Yes”, state the nature of such treatments and expected duration of treatment ___________________________________
___________________________________________________________________________________________________

Is the medical condition pregnancy? h Yes h No If “Yes”, expected delivery date:_________________________________
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7. Answer these questions based upon the employee’s own description of his/her job functions.

Is the employee unable to perform any of his/her job functions due to the condition? h Yes h No

If “Yes”, identify the job functions the employee is unable to perform:__________________________________________________________

__________________________________________________________________________________________________

*Please describe the employee’s physical and/or mental limitations or restrictions: _________________________________
_______________________________________________________________________________________________________________

8. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave and disability
benefits (such medical facts may include symptoms, or any regimen of continuing treatment such as the use of specialized equipment):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

PART B: Amount of Leave Needed and Estimated Return to Work

9. Will the employee be incapacitated for a single continuous period of time due to his/her medical condition, including any time
for treatment and recovery? h Yes h No

If “Yes”, estimate the beginning and ending dates for the period of incapacity: _____________________________________

__________________________________________________________________________________________________

10. Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced schedule because
of the employee’s medical condition? h Yes h No
If “Yes”, are the treatments or the reduced number of hours of work medically necessary? h Yes h No

Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each
appointment, including any recovery period: _______________________________________________________________

Estimate the part-time or reduced work schedule the employee needs, if any:
_____hour(s) per day; _____day(s) per week from through_____________________________________________________

11. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job functions? h Yes h No
Is it medically necessary for the employee to be absent from work during the flare-ups? h Yes h No
If “Yes”, explain:_________________________________________________________________________________________________
Based upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of flare-ups
and the duration of related incapacity that the patient may have over the next 6 months (e.g., 1 episode every 3 months lasting 1-2 days):
____________________________________________________________________________________________________

12. When do you think your patient will be able to return to work in their occupation?
h Full-time___________________ h Part-time______________________
*Please submit supporting medical evidence to support your decision (e.g., office visit notes, diagnostic test results).
*The above statements are true and complete to the best of my knowledge and belief. I have read and understand the attached Fraud Warning Statements.

________________________________________________________________ ________________________________
Signature of Health Care Provider (No stamps please) Date

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY IS NOT RESPONSIBLE FOR CHARGES INCURRED DUE
TO COMPLETION OF THIS FORM. THE PATIENT IS RESPONSIBLE FOR ANY CHARGES ASSOCIATED WITH FORM
COMPLETION.
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FRAUD NOTICES. For your protection, certain states require that the following notices appear on this
form.
Alabama. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit
or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
Alaska. A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a
claim containing false, incomplete or misleading information may be prosecuted under state law.
Arizona. For your protection Arizona law requires the following statement to appear on this form. Any
person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and
civil penalties.
Arkansas, Louisiana, Rhode Island and West Virginia. Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to fines and confinement in prison.
California. For your protection California law requires the following to appear on this form: Any person who
knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be
subject to fines and confinement in state prison.
Colorado. It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an
insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of
an insurance company who knowingly provides false, incomplete, or misleading facts or information to a
policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant
with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado
Division of Insurance within the Department of Regulatory Agencies.
Delaware. Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a
statement of claim containing any false, incomplete or misleading information is guilty of a felony.
District of Columbia. It is a crime to provide false or misleading information to an insurer for the purpose
of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an
insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.
Florida. Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of
claim or application containing any false, incomplete, or misleading information is guilty of a felony of the third
degree.
Idaho. Any person who knowingly, and with intent to defraud or deceive any insurance company, files a
statement or claim containing any false, incomplete or misleading information is guilty of a felony.
Indiana. A person who knowingly and with intent to defraud an insurer files a statement of claim containing
any false, incomplete, or misleading information commits a felony.
Kentucky. Any person who knowingly and with intent to defraud any insurance company or other person files
a statement of claim containing any materially false information or conceals, for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
Maine. It is a crime to knowingly provide false, incomplete or misleading information to an insurance company
for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance
benefits.
Maryland. Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss
or benefit or knowingly and willfully presents false information in an application for insurance is guilty of a
crime and may be subject to fines and confinement in prison.
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Minnesota. A person who files a claim with intent to defraud or helps commit a fraud against an insurer is
guilty of a crime.
New Hampshire. Any person who, with a purpose to injure, defraud or deceive any insurance company, files
a statement of claim containing any false, incomplete or misleading information is subject to prosecution
and punishment for insurance fraud, as provided in RSA 638:20.
New Jersey. Any person who knowingly files a statement of claim containing any false or misleading
information is subject to criminal and civil penalties.
New Mexico. Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or knowingly presents false information in an application for insurance is guilty of a crime and may
be subject to civil fines and criminal penalties.
New York. Any person who knowingly and with intent to defraud any insurance company or other person files
an application for insurance or statement of claim containing any materially false information or conceals for
the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance
act, which is a crime and subject to a civil penalty not to exceed five thousand dollars and the stated value
of the claim for each such violation.
Ohio. Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer,
submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma. Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any
claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is
guilty of a felony.
Oregon. Any person who knowingly and with intent to defraud any insurance company or other person: (1)
files an application for insurance or statement of claim containing any materially false information; or, (2)
conceals for the purpose of misleading, information concerning any material fact, may have committed a
fraudulent insurance act.
Pennsylvania. Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing any materially false information
or conceals for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Puerto Rico. Any person who knowingly and with the intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a
loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and,
upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000)
and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both
penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a
maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2)
years.
Tennessee, Virginia, and Washington. It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of defrauding the company. Penalties include
imprisonment, fines and denial of insurance benefits.
Texas. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of
a crime and may be subject to fines and confinement in state prison.
FOR ALL OTHER STATES EXCLUDING CONNECTICUT AND KANSAS. A person may be committing
insurance fraud, if he or she submits an application or claim containing a false or deceptive statement with
intent to defraud (or knowing that he or she is helping to defraud) an insurance company.

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