Case 2:18-cv-01582-CKJ Document 40-6 Filed 11/27/19 Page 1 of 4




           EXHIBIT F
                    Case 2:18-cv-01582-CKJ Document 40-6 Filed 11/27/19 Page 2 of 4
                                                                                                                                                                             No. 7462                          P.   2
 Apr.    28.     2017 12:41PM




                                                                                                   To Em Jo eee.: 'Please complete the following information:
               University of Washington Medical Centers                                                                                                                   6---Rzy CX!.._'
                                                                                                   Name:                                'ILL ,64.
        Parnily and Medical Leave Certification                                                     De.t.: a                     ipkelfe,gziegEM:g5..3Do3b
                of Health Care Provider for                                                        'Employee Phone: c9/9/22z4&5:2:;:96y2g____
             Personal Serious Health Condition                                                     Em v o ee email:
  To Employee: Complete the upper right corner of this page                                       )4fiarborview Medical Center                                       ii   11W Medical Center
                                                                                                     -Ian Resources Operations Office                             Human Resources Operations Office
  and arrange for your health care provider to complete the
                                                                                                  325 Ninth Avenue                                                1959 NE Pacific
  remainder of the fem. Return the completed form as                                              Box 355 715                                                     Room BB150, Box 356054
  soon as poseible, but no later than 15 calendar days                                            Seattle, WR 98104- 2499                                         Seattle, WA 98195
  after the date you receive It Return it to the appropriate                                      Phone; 978.379.9124                                           Phone: 978.379.9124
    office indicated In the space to the right. Contact this office if                            Fax: 978.379.9124                                             Fax: 978.379.9124
                                                                                                  Or, send scan to: velezkyle@example.org                                Or, send scan to; UWMCFNIACOuw.edu
    you believe that you will not be able to return the completed
    form within the specified time period.
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                                        :
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 Our employee is requesting leave from work and/or a modified work schedule under the EMLA for a health
 condition. Please provide the information requested below se that WO Can process our employee's leave
 request. only provide information regarding the condition(s) that relate to our employee's request to take
 leave or adopt a modified work schedule.
  The 6-enetic- Inn)rmatiOn Norescrlrnination Act of 2008 (GINA) prohibits- employers- and oilier entities °Awed by GINA lib'e LI from requesting or
 requiring genetic /aromatic,' of an Individual or tbmily member of the IMINduel, except as specilfcal6( allowed by this law. To comply with tills law, we
 are asking that you not provide any genetic information When responding to this request for medical inkamation, 'Gone& Information' as defined by
 GINA, indudes an indivklbal's family medical history, the resats o f an inrlivtduals or faini*, member's genetic' tests; the fact that an individual or en
 individuarg famly member sovyitt or received genetic senAces, and genetVIrformation of 0 kills carried by anirdividual or arrindividaan Taney
 member or an embryo lageuity WI by,3ritnatmwor Imnlly inettlher recelOng ossistive repmdactlyeServIces.

 Describe the medical facts related to the condition(s) that require our employee to be off work and/or to work a reduced or Intermittent
 work schedule (medical facts may include symptoms, diagnosis, or any plan for continuing treatment or therapy):
     p -e- 1 s ina.v or\9 11,\Cycloased cd-Oc(e.-e-L,1 \iv k-tiel teak 6 cL4-1-0,.zifi,c; avid
      c t evaked to 1 (--)() Pvvc, S teL\Pse CleS 0 C la t'e el wt -l,1 VUOInC- She
      v\eects 0 u\Jee-14--s off- 6-E cA)0((k-k-20 kva.kic-e_                      vs        Doke                                                                                                           -



        avvpse (-{,                   c et.A.-fectix-lq k et- LA, orf4-, steer), ttoock vY,e5st., te
             (14                                   ia eJ
                                                      hospital, hospice, or residential medical care facility? Yes 0 NA
 Was your patient ad           ed for an ow night stay in
 If yes, dates of admission:           'IAA_
 Date(s) you treated patient for this condition:
                                                                                     (re I        20         (-
 Will your patient need to have treatment visits at least twice per year due to the condition? Yeses. No 0

 Was medication, other than over-the-counter medication, prescribed?                                                                               Yes?        .No   f:1:1k.33ec:265c:71fe:e26d:2682:4ec2:aaa1:99ab.:.*33ec:265c:71fe:e26d:2682:4ec2:aaa1:99ab:   's, -'-'...'IS)




 Was your patient referred to other health care provider(s) for evaluation or treatment?                                                           Yes 0 No 0

 If yes, describe the nature and expected duration of the treatments:




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                                                                                                                                                   ,:ess.
                                                                                                                                                    :a:                                                        ,    '''.'   A
 Expected date of delivery:                            Expected dates of your patient's physical incapacity due to pregnancy and delivery (not
                       -----                           parental leave):
 Planned C'-Section?       Yes   0 No 0                From (date):                                                             to (date):

Rev 3/2016




                                                                                                                                                            Buell Realtime Reporting
                                                                                                                                                                                                                            UVVM B002903
                                                                                                                                                                  978.379.9124
                 Case 2:18-cv-01582-CKJ Document 40-6 Filed 11/27/19 Page 3 of 4
  14.. 28.      2017 12:42PM                                                                                            No, 7462




       i0,                 .  .. .0 .0      ogktrt
 Several of the following questions ask about the frequency or duration of a condition or treatment. We know that health
 conditions can vary or change over time, so please provide your best estimate Irr response to these questions, being as
 specific as you can. Using terms such as "lifetime," "unknown," or "indeterminate' may not be specific enough for us to
 determine leave eligibility for our employee under the Family and Medical Leave Act.
 Coati /0041S Leave;
 Will your patient be incapacitated for a singles continuous period of time including time for tteairrient and recovery? Yes 0 No 0
 If yes, estimate the beginning and ending dates for the period of Incapacity;
                                                                                         }.:r_
 From (date): 01-4-            Ato                 to (date):           ,,,\L/3.-ne.



  ntermittent Leave:
 Will the condition(s) cause episodic flare-ups that prevent your patient from performing his/her job functions? Yes 0 No 0
 If yes, please explain;



 Based upon your patient's medical history and your knowledge of the medical condition, estimate the frequency of flare-ups and the
 duration of relaW incapacity that the patient may have over the next 6 months (e.g,, 1 time per 3months, 2 days per episode)

 Prim uency:                   time(s) per       vveek(s) -or-                   month(s)
AND
 Duration:                 hours or          day(s) per episode
 From (date):                                           to (date):

AlaPointreents:
Are follow -op and/or periodic treatment appointments medically -necessary fir your patient? Yes Li No 0
If yes, describe the anticipated treatment schedule and any treatment recovery period(s):

       'PC4         ce-e cok.)1,"e[cA7                    Cc5 e"\                           retiLC,CC-LIC,
Will there be a. need for planned medical appointments and/or absences? Yes 0 No Pa,                                         ECEIVED-
Frequency:                     time(s) per       week(s) -or-                    month(s)
AND                                                                                                                      APR:      .8 217
Duration                   hours: or         day(s) per episode
From (date):                                       .    to (tiate).!                                               HMO lO,A1lAti: REGO:VR:65:S

ReducedtMedifig_d Work Schedule:

Will your patient require a reduction in or modification of the amount of time worked per week due to his/her medical condition, including
any time for treatment and recovery? Yes 0 No 0
If yes, describe the reduced or modified work Schedule that you believe is medically necessary:



This work schedule needs to be in place from Cdate):-                                              to (date):

  ea                  erInftiritiat          easwtiiint OteittK

Name (please print)    1206.1,12eL                                                     Specialty     PIA
Business      Addressil 00 10841 4,e_ME                           t3a          to()     phone 4AS               -14.5se) Fax 4,2_5-L-55 -4.5
                     1 ev           cleCo

Health Care Provider Signature (required)                 0,41,                                             Date      OL-1
                               Reehef-S                A.Pt
Rev 312.0/6            Overtake Medical Clinics
                      400 108th Ave NE Ste, 100

                                                                                                                                            UWM 8002904
               Case 2:18-cv-01582-CKJ Document 40-6 Filed 11/27/19 Page 4 of 4
 Apr, 28.     7017 1241PM                                                                                                               No. 7462     P.   1.




0 OVEREAF
   MEDICAL CLINKS
                  DOWN TOW \


                                                                                                            400 10e Ave NE, Suite 100
                                                                                                                      Bellevue, WA 98004
                                                                                                                     978.379.9124 Phone
                                                                                                                       978.379.9124 Fex



        To:
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        From:         fitctr-lci                                              Pags:           'o
        Phone: .,41 As -45'S -4,,, aSo )4. (.,:,34-1,3                        Date:

        Re'               ay-f-inf We R, zsi C -L:
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      ?RANK you




                                                                                                                                                          UWM B002905

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