PDF
… residential medical care facility?
No
Yes
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?
No
Yes
Was medication, other than over-the-counter medication, prescribed?
No
Yes
Was the patient referred to other health care provider(s) for…
https://www.wichita.edu/services/humanresources/Total_Rewards/Leave/Shared_Leave/CHCP_Employee_Non-FMLA.pdf