Cigna Leave Solutions®

Claims Service Center

P.O. Box 703509
Dallas, TX 75370

Jose Garcia
106 N Butrick St
Waukegan, IL 60085
Cigna Leave Solutions®
www.mycigna.com

Phone: 888.842.4462
Fax: 866.931.5095

09/11/2017

FML Leave ID#: 178848094059

Re: Acknowledgement of Request for Leave Eligibility Notice for Child - analicia salinas

Dear Jose Garcia,

We received your leave of absence request for Family Health Condition.

Your Eligibility Status

The grid below provides a visual breakdown of your available leave plan(s) and the eligibility
status for each. If you have questions about your available leave plans, please give us a call at
888.842.4462.

Plan Absence Type From Eligibility Through*

Reason
FMLA Intermittent 06/20/2017
Eligible- 12/20/2017
Leave Pending
Determination
*If you did not know your leave end date when you filed your leave, the “Through” date listed
above is a default date. Please note that being eligible for leave does not mean that your
request is approved.
Plan Time Used as of 09/11/2017 * Time Remaining as of 09/11/2017 *
FMLA 184 hour(s) / 4.6 week(s) 296 hour(s) / 7.4 week(s)
*Time Used and Remaining are based on your work schedule at the time you filed your leave.
This includes time used in this leave and any other leave within the current leave period. These
reflect only the time reported to date and may be subject to change.

Sometimes your leave dates or eligibility status can change. If this happens, we want to keep
you informed so you will receive an updated copy of this letter. Please look at the grid for the
updates. If you have any questions, please give us a call at 888.842.4462.

What you need to do

Please see the enclosed certification form. This should be completed and returned to Cigna
within 15 calendar days of the date of this letter. Failure to return the form may result in the
denial of your leave. You may return the form to Cigna using one of the following methods:

 Mail: Address is listed on the certification form

 Fax: 866.931.5095
 Email: FMLACertifications@Cigna.com

You will want to review any additional enclosed attachments. Some attachments may need
action on your part, and some may just be information for your records.

Page 1 of 4
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Life Insurance Company of North America, Cigna
Life Insurance Company of New York, and Connecticut General Life Insurance Company. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual
Property, Inc.
You are required to keep your employer updated on your status. Please refer to your employer’s
procedures for specific information.

Additional Information

If you’d like to see your leave information, please log on to www.mycigna.com, and click
“Claims” under the “Manage Claims and Balances” tab. On this page, click on “Request or
Check a Leave of Absence” on the right column on your screen.

Remember, we’re here if you need us. If you have any questions, please call us at
888.842.4462.

Sincerely,

Cigna Leave Solutions®

Enclosures:
Frequently Asked Questions and Important Information
Certification of Family Health Care Provider Form
FMLA Notice of Rights
Life Assistance Program

Page 2 of 4
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Life Insurance Company of North America, Cigna
Life Insurance Company of New York, and Connecticut General Life Insurance Company. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual
Property, Inc.
Frequently Asked Questions and Important Information
Enclosed you will find information on your rights under the Family and Medical Leave Act of
1993 (FMLA).

What is Family Medical Leave?

The Family and Medical Leave Act and similar state laws (FML) entitle eligible employees to
take unpaid, job-protected leave for specified family and medical reasons.

What about your Healthcare Coverage?

Your employer requires you to pay your health and welfare portion of benefits while you are on
leave. The Benefits Specialist will send you a letter (to the address on file in ADP) detailing the
specifics of your leave, rates, and payment information and consequences for failure to make
timely payments.

Are you aware of the Health Advocacy Services?

We would like to let you know about health advocacy services available to you and your
family members, including parents and parents-in-law, through Health Advocate Inc.
Personal Health Advocates – experienced clinicians or benefit specialists are available to
help you resolve many of the complex healthcare, health insurance or medical bill
challenges you may face. Contact your employer to obtain the Health Advocate phone
number and additional details.

What about your Paid Time Off (PTO)?

Your employer’s policies will require that an employee use all forms of accrued paid leave which
runs concurrently with unpaid FMLA leave. Should you not meet the terms and conditions of the
paid leave policy, you remain entitled to unpaid leave.

Have you heard about the Life Assistance Program?

We would like to take this opportunity to let you know about Cigna's Life Assistance Program - a
special program available to you and your household members to help you balance your health,
work and family needs. The Life Assistance Program can help you with many different kinds of
support including child care, elder care, counseling for family or personal issues, and assistance
finding local support services. All services are free, confidential, accessible 24 hours/day, 365
days/year. Should you require services beyond the scope of the program, the Life Assistance
staff coordinates referrals to appropriate resources as needed. Please dial the Life Assistance
toll-free number 1.800.538.3543 for assistance and visit www.cignabehavioral.com/cgi to learn
more about the available services.

What does “Intermittent Leave” mean?

Intermittent leave means that you will be working your normal schedule, but may occasionally
miss time from work due to your FML Leave.

Additional information regarding your leave

Page 3 of 4
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Life Insurance Company of North America, Cigna
Life Insurance Company of New York, and Connecticut General Life Insurance Company. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual
Property, Inc.
To determine your available leave time under the FMLA, your company utilizes a rolling
backward calculation method. This means you will gain back the leave time you’ve taken one
calendar year from the date you used leave time.

Upon your timely return from federal and/or state Family and Medical Leave (FML) and/or a
company job-protected leave, you will be restored to the same or an equivalent job with
equivalent pay and benefits as required by law.

Page 4 of 4
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Life Insurance Company of North America, Cigna
Life Insurance Company of New York, and Connecticut General Life Insurance Company. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual
Property, Inc.
 Cigna Leave Solutions®
Certification for Health Care Provider for Family Member’s
Serious Health Condition
___________________________________________________________________________________________________________________________________________________________________________________________________________

Date Prepared: 9/11/2017

Must Be Returned By: 9/26/2017

Employee Name: Jose Garcia

Employer Name: Ceannate Corp.

Leave ID: 178848094059

Reason for requesting leave: Family Health Condition

Leave date(s)/Period(s) requested: 06/20/2017 - 12/20/2017

SECTION I: For Completion by the EMPLOYEE

INSTRUCTIONS to the EMPLOYEE: Please complete Section I before giving this form to your family member or his/her
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 to care for a covered family member with a 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). 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. § 825.305(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

Name of family member for whom you will provide care:_______________________________________________________

Relationship of family member to you: ____________________, If child, date of birth: _______________________________

Describe care you will provide to your family member and estimate leave needed to provide care:
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Employee Signature _________________________________________ Date__________________________

See reverse to provide additional information

Cigna Leave Solutions® • P.O. Box 703509 • Dallas, TX 75370 • Fax: 866.931.5095 • Phone: 888.842.4462
Certification of Health Care Provider Client: CEANN Document ID: Leave ID: 178848094059

Page 1 of 4
SECTION II: For Completion by the HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested leave under the FMLA to care for your
patient. Answer, fully and completely, all applicable parts below. 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 patient needs leave. Page 3 provides space for additional information, should
you need it. 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 ___________________________________ and phone #____________fax #______________
Address__________________________________________________________________________________
Type of practice / Medical specialty: _____________________________________________________________
Please complete the following:
2. Approximate date condition commenced:___________________ Expected Duration:____________________

3. 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 :___________________________________________________________

4. Date(s) you treated the patient for condition 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. Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)? ___No __Yes
If yes, state the nature of such treatments and expected duration of treatment:
______________________________________________________________________________________________________

8. Is the medical condition pregnancy? __No __Yes; If yes, expected delivery date: ______________________
9. 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) If this leave is to care for a child 18 years of age or older, please provide specific
Activities of Daily Living the child may need assistance in performing (i.e. bathing, cooking, hygiene, taking public
transportation, etc.). (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):
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

***AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that your patient’s need for care by the
employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or transportation needs, or the
provision of physical or psychological care: ***

Subsection B: Must be completed for all CONTINUOUS LEAVES:

1. Will the patient be incapacitated for a single continuous period of time due to his/her medical condition, including any
time for treatment and recovery? ___No ___Yes

If yes, estimate the beginning and ending dates for the period of incapacity:

Start Date __________________________ End Date ____________________________

During this time, will the patient need care? _____No ____Yes If yes, explain the care needed by the patient and why such
care is medically necessary:_______________________________________________________________________________
______________________________________________________________________________________________________
(Form is considered incomplete/insufficient if not provided for a continuous leave)

Cigna Leave Solutions® • P.O. Box 703509 • Dallas, TX 75370 • Fax: 866.931.5095 • Phone: 888.842.4462
Certification of Health Care Provider Client: CEANN Document ID: Leave ID: 178848094059

Page 2 of 4
Subsection C: Must be completed for all REDUCED SCHEDULE LEAVES.
1. Is it medically necessary for the employee to work part-time or a reduced schedule because of the patient’s
condition? ___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__________________________

During this time, will the patient need care? _____No ____Yes If yes, explain the care needed by the patient and why such
care is medically necessary:_______________________________________________________________________________
_____________________________________________________________________________________________________
(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 employee 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: __________ hour(s) per day ________ days per episode

Frequency: _______ times per ________ week(s) / month(s) (circle one)

During this time, will the patient need care? _____No ____Yes If yes, explain the care needed by the patient and why such
care is medically necessary:_______________________________________________________________________________
_____________________________________________________________________________________________________
(Form is considered incomplete/insufficient if not provided for an intermittent leave)

ADDITIONAL INFORMATION:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
____________________________________________________ ________________________________________
Signature of Health Care Provider Date
See reverse to provide additional information
Cigna Leave Solutions® • P.O. Box 703509 • Dallas, TX 75370 • Fax: 866.931.5095 • Phone: 888.842.4462
Certification of Health Care Provider Client: CEANN Document ID: Leave ID: 178848094059

Page 3 of 4
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. § 825.500. 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 20210. DO NOT SEND THE COMPLETED FORM TO THE WAGE AND HOUR DIVISION.

*PLEASE BE SURE TO RETURN ALL PAGES

Return completed certification form to:

Cigna Leave Solutions® P.O. Box 703509 Dallas, TX 75370
Fax: 1.866.931.5095
Email: FMLACertifications@Cigna.com

Cigna Leave Solutions® • P.O. Box 703509 • Dallas, TX 75370 • Fax: 866.931.5095 • Phone: 888.842.4462
Certification of Health Care Provider Client: CEANN Document ID: Leave ID: 178848094059

Page 4 of 4
 EMPLOYEE RIGHTS AND RESPONSIBILITIES
UNDER THE FAMILY AND MEDICAL LEAVE ACT
Basic Leave Entitlement
FMLA requires covered employers to provide up to 12 weeks of unpaid,
job-protected leave to eligible employees for the following reasons:
 For incapacity due to pregnancy, prenatal medical care or child
birth;
 To care for the employee’s child after birth, or placement for
adoption or foster care;
 To care for the employee’s spouse, son or daughter, or parent,
who has a serious health condition; or
 For a serious health condition that makes the employee unable to
perform the employee’s job.
Military Family Leave Entitlements
Eligible employees whose spouse, son, daughter, or parent on covered
active duty or call to covered active duty status may use their 12-week
leave entitlement to address certain qualifying exigencies. Qualifying
exigencies may include attending certain military events, arranging for
alternative childcare, addressing certain financial and legal arrangements,
attending certain counseling sessions, and attending post-deployment
reintegration briefings.
FMLA also includes a special leave entitlement that permits eligible
employees to take up to 26 weeks of leave to care for a covered
servicemember during a single 12-month period. A covered
servicemember is:
(1) a current member of the Armed Forces, including a member of the
National Guard or Reserves, who is undergoing medical treatment,
recuperation or therapy, is otherwise in outpatient status, or is otherwise on
the temporary disability retired list, for a serious injury or illness*; or (2) a
veteran who was discharged or released under conditions other
than dishonorable at any time during the five-year period prior to the first
date the eligible employee takes FMLA leave to care for the covered
veteran, and who is undergoing medical treatment, recuperation, or therapy
for a serious injury or illness.*.
*The FMLA definitions of “serious injury or illness” for current
servicemembers and veterans are distinct from the FMLA definition
of “serious health condition”.
Benefits and Protections
During FMLA leave, the employer must maintain the employee’s health
coverage under any “group health plan” on the same terms as if the
employee had continued to work. Upon return from FMLA leave, most
employees must be restored to their original or equivalent positions with
equivalent pay, benefits, and other employment terms.
Use of FMLA leave cannot result in the loss of any employment benefit
that accrued prior to the start of an employee’s leave.
Eligibility Requirements
Employees are eligible if they have worked for a covered employer for at
least 12 months, have 1,250 hours of service in the previous 12 months*,
and if at least 50 employees are employed by the employer within 75
miles.
*Special hours of service eligibility requirements apply to airline
flight crew employees.
Definition of Serious Health Condition
A serious health condition is an illness, injury, impairment, or physical or
mental condition that involves either an overnight stay in a medical care
facility, or continuing treatment by a health care provider for a condition
that either prevents the employee from performing the functions of the
employee’s job, or prevents the qualified family member from
participating in school or other daily activities.
Subject to certain conditions, the continuing treatment requirement may be met by a
period of incapacity of more than 3 consecutive calendar days combined with at least
two visits to a health care provider or one visit and a regimen of continuing treatment,
or incapacity due to pregnancy, or incapacity due to a chronic condition. Other
conditions may meet the definition of continuing treatment.
Use of Leave
An employee does not need to use this leave entitlement in one block. Leave can be
taken intermittently or on a reduced leave schedule when medically necessary.
Employees must make reasonable efforts to schedule leave for planned medical
treatment so as not to unduly disrupt the employer’s operations. Leave due to
qualifying exigencies may also be taken on an intermittent basis.
Substitution of Paid Leave for Unpaid Leave
Employees may choose or employers may require use of accrued paid leave while
taking FMLA leave. In order to use paid leave for FMLA leave, employees must
comply with the employer’s normal paid leave policies.
Employee Responsibilities
Employees must provide 30 days advance notice of the need to take FMLA leave when
the need is foreseeable. When 30 days notice is not possible, the employee must
provide notice as soon as practicable and generally must comply with an employer’s
normal call-in procedures.
Employees must provide sufficient information for the employer to determine if the
leave may qualify for FMLA protection and the anticipated timing and duration of the
leave. Sufficient information may include that the employee is unable to perform job
functions, the family member is unable to perform daily activities, the need for
hospitalization or continuing treatment by a health care provider, or circumstances
supporting the need for military family leave. Employees also must inform the
employer if the requested leave is for a reason for which FMLA leave was previously
taken or certified. Employees also may be required to provide a certification and
periodic recertification supporting the need for leave.
Employer Responsibilities
Covered employers must inform employees requesting leave whether they are eligible
under FMLA. If they are, the notice must specify any additional information required
as well as the employees’ rights and responsibilities. If they are not eligible, the
employer must provide a reason for the ineligibility.
Covered employers must inform employees if leave will be designated as
FMLA-protected and the amount of leave counted against the employee’s leave
entitlement. If the employer determines that the leave is not FMLA-protected, the
employer must notify the employee.
Unlawful Acts by Employers
FMLA makes it unlawful for any employer to:
 Interfere with, restrain, or deny the exercise of any right provided under
FMLA;
 Discharge or discriminate against any person for opposing any practice made
unlawful by FMLA or for involvement in any proceeding under or relating to
FMLA.
Enforcement
An employee may file a complaint with the U.S. Department of Labor or may bring a
private lawsuit against an employer.
FMLA does not affect any Federal or State law prohibiting discrimination, or supersede
any State or local law or collective bargaining agreement which provides greater family
or medical leave rights.
FMLA section 109 (29 U.S.C. § 2619) requires FMLA covered employers to post
the text of this notice. Regulations 29 C.F.R. § 825.300(a) may require additional
disclosures.