Notice of Eligibility and Rights & Responsibilities

Allina Health Provided Leave

Jessica Eckstrom
1140 Landmark Trail S.
Hopkins, MN 55343

To: Jessica Eckstrom

From: Allina Health Leave of Absence Service Center
Date: 10/16/2018

On 10/16/2018 you informed us of your request for a leave of absence. This letter and its enclosures
provides you important information regarding Allina Health’s Leave Policies. It is important that you
read through these documents carefully.

You requested leave for Employee Medical Leave to begin on 10/13/2018. Based on our review, we have
determined your request for leave is not covered under the Family and Medical Leave Act (FMLA) as you
have not worked a minimum of the required 1,250 hours within the previous 12 months. You have
worked 1, 073 hours as of 10/13/2018.

Leave Certification Requirements

Although we have determined you are not eligible for FMLA, you are eligible for other Allina Health
provided leave. You must provide us the enclosed Certification Form as soon as possible, but no later
than 10/30/2018. If sufficient information is not provided in a timely manner, your leave may be denied,
which may result in discipline under Allina Health’s attendance policies. The documentation should be
returned to Allina Health using one of the following methods:

Fax: 612-262-4699
Email: HRLOAHRSC@allina.com
Mail: P.O. Box 1469 (MR)
Minneapolis, MN 55440-1469

If for some reason you are unable to submit the enclosed certification form by 10/30/2018, you must
provide information to the Allina Health Leave of Absence Service Center regarding any extenuating
circumstances outside your control that prevented you from meeting with your Health Care Provider.
This information must be provided prior to the due date stated above.

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Employee Responsibilities During Leave

If it is determined that your leave does qualify as company provided leave, you will have the following
responsibilities:

 Foreseeable Leave Notification: If you have requested a planned leave, you are required to provide at
least 30 days advanced notice to your manager and the Allina Health Leave of Absence Service
Center. If 30 days advanced notice is not possible, you must provide notice of the need for leave as
soon as possible and practicable.

 Unforeseeable Leave: Allina Health leave policies do not provide for unplanned leave that is not
covered by FMLA. Such absences will be subject to your applicable attendance policy.

 Benefit Deductions: While you are receiving pay from Allina Health, deductions will continue to be
taken from your pay check. If you no longer receive pay, you must contact the Allina Health Leave of
Absence Service Center to discuss your benefit options.

 Impact on Pay: You are required to use any accrued and available frozen sick leave and paid time off.
Any paid leave will also be considered Company Leave.

 Return to Work: You are expected to return to work the day following your approved leave. If the
circumstances of your leave change and you are able to return to work earlier than the date you
indicated, you will be required to notify us at least two workdays prior to the date you intend to
report for work.

 Fitness for Duty: If you are on leave for two or more consecutive weeks, you must provide a return to
work certification to the Allina Health Leave of Absence Service Center prior to your return to work.

 Return to Work Extensions: If you need to extend your leave, you will typically be required to provide
updated medical information prior to the expiration of any approved leave. In addition, upon request
you will be required to furnish periodic updates of your status and intent to return to work.
***

If you have any questions, require additional information, or experience a change in your circumstances;
please contact Allina Health Leave of Absence Service Center Monday through Friday, 8:00 a.m. to 4:30
p.m. at 612-262-4688 or toll free at 1-877-992-8099. TTY/TDD callers may call the National Relay service
at 1-800-855-2880 and request 1-877-992-8099.

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Certification of Health Care Provider for Employee’s Serious
Health Condition

Employee Name: Jessica Eckstrom Employee Id: 10709871

Job Title: RN

Instructions for EMPLOYEE: PLEASE READ

This Certification is broken into Section I and Section II. Section I only needs to be completed if you are
applying for income protection benefits. If you do not wish to apply for income protection, please notify your
health care provider NOT to complete Section I. Section II must be completed for you to qualify for leave and
must be competed regardless of whether you are applying for income protection.

You are responsible for providing this form to your health care provider and ensuring that they return it to
Allina Health. It is important that your health care provider answers the questions on this form related to your
medical condition. Failure to provide the information requested may result in a denial of your request for leave
under the Family and Medical Leave Act, applicable state leave laws, and/or company specific leaves, which
may lead to discipline under Allina Health attendance policies.

We are required to provide you with at least 15 calendar days to return a complete and sufficient form. The
due date for your certification form is: 10/30/2018. It is your responsibility to ensure that the certification is
provided in a timely manner. If your health care provider does not send the form to Allina Health on your
behalf, then you are responsible for returning it to the Allina Health Leave of Absence and Disability Service
Center at:

Allina Health Leave of Absence Service Center

PO Box 1469
Minneapolis, MN 55440-1469
Phone: 612-262-4688
Fax: 612-262-4699

Instructions for the HEALTH CARE PROVIDER

Your patient has requested income protection under Allina Health’s polices and/or leave under The Family and
Medical Leave Act, applicable state leave, and/or company specific leaves. Please answer, fully and completely,
all applicable parts. Several questions seek a response as to the frequency or duration of the 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. Limit your responses to the condition for which the employee is
seeking leave. Do not provide information about genetic tests, as defined in 29 C.F.R. § 1635.3(f), genetic
services, as defined in 29 C.F.R. § 1635.3(e), or the manifestation of disease or disorder in the employee’s family
members, 29 C.F.R. § 1635.3(b). Please be sure to sign the form on the last page.

Your patient is required to return a complete and sufficient certification form no later than 10/30/2018.
Once this form is completed, please return via fax to: 612-262-4699.

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Employee Name: Jessica Eckstrom Employee ID: 10709871

Provider Information

Provider Name: _______________________________________________________________________________

Type of Practice/Specialty: _____________________________________________________________________
Business Address: ____________________________________________________________________________
Street: __________________________________________________________ Postal Code: ________________
City: _______________________________________________ State: _______________
Phone: ________________________________ Fax: _____________________________

SECTION I – Required for Income Protection Eligibility Determination

1. Objective findings: HT: WT: BP: TEMP: PULSE: RESP:
2. Patient’s Complaints:

__________________________________________________________________________________________
3. Your Diagnosis: (list all disabling diagnoses including all ICD10 codes)
Primary: ICD10 Code: ______________ Description:
Secondary: ICD10 Code: ______________ Description:
ICD10 Code: ______________ Description:
4. Describe objective/clinical findings to warrant disability, including severity and duration based the patient’s
presentation during office visits.

5. When was patient first diagnosed with this condition? _____/_____/_____

List all medications, identify dates of new medications or dose adjustments: (attach list if necessary)
Medication Dose Frequency Duration New Med Adjusted Med Date Adjusted
Yes  No  Yes  No  _____/_____/_____
Yes No  Yes  No  _____/_____/_____
Yes No  Yes  No  _____/_____/_____
Yes  No  Yes  No  _____/_____/____

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Employee Name: Jessica Eckstrom Employee ID: 10709871

6. Is this condition the result of an injury? Yes  No  Is this condition work related? Yes  No 
If yes, provide date and description of event:

List all co-morbid conditions:

7. If patient is pregnant, indicated estimated date of delivery _____/_____/_____

8. Is a C-Section planned? Yes  No  If so what is the date of the planned C-Section? _____/_____/____
9. Give all dates of treatments by you during this period of disability; also indicate date of follow up visit:

10. What is the prescribed treatment plan? (please provide specific details regarding treatment/therapy, attach
notes if necessary):

11. Have there been any Emergency Room visits OR Hospitalizations during this current disability period?
Yes  No 
If Yes:  Emergency Room visit  Hospitalization  23 hour admission
Name and address of hospital or facility

Date of admission: _____/_____/_____ Date of discharge: _____/_____/_____

Indicate treatment provided:
12. Has any surgical procedure related to current disability been performed or is any anticipated?
Yes  No 
List the name of the procedure:
CPT code:
Date of procedure: _____/_____/_____
13. Has patient been referred to other physician(s)/specialist? Yes  No  If yes, provide physician name,
specialty, and telephone number.

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Employee Name: Jessica Eckstrom Employee ID: 10709871

14. List specific functional limitations of Activities of Daily Living (ADL’s):

15. Is the patient unable to perform any of his/her job functions due to the condition? Yes  No 
If yes, identify the job functions the employee is unable to perform:

16. Has patient been given any driving restrictions for this disability period? Yes  No 
If yes please describe: ___
__________________________________________________________________________________________
17. Based on your personal knowledge and treatment, how long has the patient been totally disabled by this
sickness and prevented from working? From _____/_____/_____ through _____/_____/_____
18. Has the patient recovered sufficiently to return to work? Yes  No 
If “Yes”, give the date the patient was able to return to work _____/_____/_____
If “No”, in your opinion when, may work be resumed? (Please do not use “indefinite”, “unknown”,
“undetermined”, etc.) If a date cannot be determined, please estimate in days, weeks or months, the
total duration of disability
19. Has the patient recovered sufficiently to return to restricted work? Yes  No 
If “Yes”, indicate date restrictions begin: _____/_____/_____ Date restrictions end: _____/_____/_____
Restriction (s) required:

Please attach all office notes, History & Physical, results of x-rays, laboratory tests, MRI Reports, etc, if relevant.

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Employee Name: Jessica Eckstrom Employee ID: 10709871

SECTION II – Required for Leave Eligibility Determination

PART A: MEDICAL FACTS
Note to Health Care Provider: This Part A only needs to be completed if you were instructed
not to complete Section I. If you completed Section I, please skip to Part B below.

20. Approximate date condition commenced: _____/_____/_____

Probable duration of condition:

Mark below as applicable:

Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
Yes  No 
If Yes, dates of admission: _____/_____/_____ through _____/_____/_____

Date(s) you treated the patient for condition:

Will the patient need to have treatment/visits at least twice per year due to condition? Yes  No 

Was medication, other than over-the-counter medication, prescribed? Yes  No 

Was the patient referred to any other health care provider(s) for evaluation or treatment (e.g., physical
therapist)? Yes  No 

If Yes, state the nature of such treatments:

Expected duration of treatment: _____/_____/_____

21. Is the medical condition pregnancy? Yes  No  If so, expected delivery date: _____/_____/_____
22. Is the medical leave needed for the purpose of undergoing a cosmetic procedure? Yes  No 
23. For the following question, use the job information provided by the employer. If the employer fails to provide a
list of the employee’s essential functions or a job description, 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? Yes  No 
If Yes, identify the job functions the employee is unable to perform:

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Employee Name: Jessica Eckstrom Employee ID: 10709871

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

PART B: AMOUNT OF LEAVE NEEDED

25. 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? Yes  No 

Estimate beginning and ending dates for period of incapacity: ____/____/____ through ____/____/____

26. 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? Yes  No 

If so, are the treatments or the reduced number of hours of work medically necessary? Yes  No 

Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required
for each appointment, including any recovery period (e.g. 1 appointment every 3 months, and requires 1 day
of recovery per appointment):

Frequency: appointment(s) every week(s) or month(s)

Duration: hour(s) or day(s) per appointment

Estimate part-time or reduced work schedule employee needs, if any: hours per day, days per week

Estimate beginning and ending dates _____/_____/_____ through _____/_____/_____

27. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job
functions? Yes  No 
If Yes, estimate beginning and ending dates _____/_____/_____ through _____/_____/_____
Is it medically necessary for the employee to be absent from work during the flare-ups? Yes  No 
If so, 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):

Frequency: episodes(s) every week(s) or month(s)

Duration: hour(s) or day(s) per episodes

Page 8 of 14
Employee Name: Jessica Eckstrom Employee ID: 10709871

ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWERS

_____________________________________________________________________________________________

Your patient is required to return a complete and sufficient certification form no later than 10/30/2018.
Once this form is completed, please return via fax to: 612-262-4699

__________________________________________ _____/_____/_____
Signature of Health Care Provider Date

The documentation should be returned to Allina Health using one of the following methods:

Fax: 612-262-4699
Email: HRLOAHRSC@allina.com
Mail: P.O. Box 1469 (MR)
Minneapolis, MN 55440-1469

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Return to Work Certification
This return to work certification is broken into Section I and Section II. Section I is to be
completed by you. You are responsible for providing this form to your health care provider to
complete Section II and ensuring that they return it to Allina Health at least two workdays prior
to your return to work. You may also provide a copy of this certification to your manager.

The documentation should be returned to Allina Health using one of the following methods:

Fax: 612-262-4699
Email: HRLOAHRSC@allina.com
Mail: P.O. Box 1469 (MR)
Minneapolis, MN 55440-1469

SECTION I: To be completed by the Employee

Employee Name: Jessica Eckstrom Employee Id: 10709871

Business Unit: MRC
Job Title: RN

I understand that I cannot return to work without a release from my health care provider.

Signature ___________________________________________ Date:_____/_____/_____

SECTION II: To be completed by the Health Care Provider

Provider name:
Type of Practice/Specialty:
Phone: Fax:

Return to Work:
With No Restrictions on _____/_____/_____.

With Restrictions from _____/_____/_____ to _____/_____/_____. Please complete Return to Work

Capabilities Form.

Unable to Work from ____/_____/______ to _____/_____/______. If this is an extension of the original leave,
you will receive extension paperwork requesting an update on the treatment plan and/or notes to support your
opinion and substantiate the need for extended disability.

Your patient is required to return a complete and sufficient return to work certification at least two workdays
prior to their return to work. Once this form is completed, please provide a copy to your patient and return to
Allina Health via fax to: 612-262-4699.

__________________________________________ _____/_____/_____
Signature of Health Care Provider Date

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Employee Name: Jessica Eckstrom Employee Id: 10709871

Date of Evaluation: _____/_____/_____ Next Evaluation: ____/____/_____

Is this injury/illness work related? Yes __________ No__________

Return to Work with Restrictions (outline details below) from _____/_____/_____ to ____/_____/_____.

Released to Return with No Restrictions on ____/____/____

Employee’s Capabilities
Please check only the boxes that apply
Body Part(s) Affected___________________________________
Lift/Carry
Not at all Occasional Frequent Continuous Not at all Occasional Frequent Continuous
0% 1-33% 34-66% 67-100% 0% 1-33% 34-66% 67-100%
1-10lbs. Bend
11-20lbs. Twist/Turn
21-32lbs. Kneel
33-40lbs. Squat
41-50lbs. Sit
Push/Pull (Amount of force without resistance) Stand
1-20lbs Walk
21-40lbs. Ladder/Stair
>40lbs. Drive

Hand, Wrist and Shoulder Activities: Upper Extremity Affected: Right Left Both
Not at all Occasional Frequent Continuous
0% 1-33% 34-66% 67-100%
Firm Grip/Pinch
Simple grip/grasping
Wrist Motion
Reaching Up
Reaching Out
Keyboarding

Wrist Brace

May Work up to _____ hours per day, _____ days per week, or May return to regular-hourly schedule

Other Restrictions, Considerations: ________________________________________

_____________________________________________________________________________________________
_____________________________________________________________________________________________

Once this form is completed, please provide a copy to your patient and return to Allina Health via fax to:
612-262-4699

__________________________________________ _____/_____/_____
Signature of Health Care Provider Date
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Authorization to Use or Disclose Protected Health Information

I authorize any licensed physician, health care provider, government agency, insurance or
reinsuring company, consumer reporting agency or employer to give and release any and all information
with respect to any physical or mental condition and/or treatment I have received, including any
non-medical information, to Allina Health, or to its legal representative, or to other persons or
organizations providing claims management services to any Allina Health-sponsored employee benefit
plan.

I understand that the information obtained by use of this Authorization will be used by Allina
Health to determine eligibility for benefits. The information obtained will not be released by Allina
Health to any person or organization, except insurance companies to which I submit a claim for benefits,
and to those representatives of my employer who have a business use for such information, and to
those persons or organizations providing claims management services to any Allina Health-sponsored
employee benefit plan.

I understand that I may request a copy of this Authorization. I agree that a photographic copy of
this Authorization shall be as valid as the original.

I understand that I have the right to refuse to sign this authorization and that this authorization
is subject to revocation at any time by my giving written notice that is signed. I understand that any such
revocation shall not apply to any disclosure or re-disclosure of my information made in reliance on my
initial authorization. I also understand that my failure to sign this authorization, or my subsequent
revocation of my initial authorization, may impair Allina Health’s ability to process my claim and may be
a basis for denying or terminating my claim for benefits.

THIS AUTHORIZATION WILL BECOME EFFECTIVE ON THE DATE APPEARING NEXT TO MY

SIGNATURE BELOW AND CONTINUE FOR THE DURATION OF MY CLAIM, OR FOR ONE YEAR FOLLOWING
THE EFFECTIVE DATE, WHICHEVER IS LONGER.

Employee Printed Name

Employee I.D. #

Employee Signature Date

Page 12 of 14
Additional Benefits Related Information

While you are on an approved leave of absence, the impact on your benefits depends upon the type of
leave, whether your leave of absence is paid or unpaid and whether you are eligible and entitled for
LEAVE.

If you need to add a new dependent onto health coverage, you will need to contact the Allina Health HR
Service Center within 45 calendar days from the date of birth, or placement of the child.

Contributions to the Dependent Care Reimbursement Account must be stopped per IRS guidelines
when you are absent from work.
Once you return from leave, you will need to contact the Allina Health HR Service Center within
45 calendar days to reinstate or elect a Dependent Care Reimbursement account (pre-tax
contributions for eligible day care expenses)

Any approved income will continue to be issued during the normal pay cycle and payroll processing
through Allina Health. All eligible deductions will continue to be taken from your payroll, except
contributions to the Dependent Care Reimbursement Account.

If your leave of absence is LEAVE entitled and considered unpaid, where you are not receiving a
paycheck through Allina Health payroll processing, the missing benefit premiums will be taken upon
your return from leave as benefit arrears.

If your leave of absence is not eligible for LEAVE, or if your absence has exhausted LEAVE entitlement
and considered unpaid, where you are not receiving a paycheck through Allina Health payroll
processing, your benefits will transition to Flex Compensation, Inc. the first of the month following your
last check issued through Allina Health payroll.

If your leave of absence is denied, your benefits will end following your first day absent or your last
day on approved leave, whichever is later.

Additional information regarding Leave of Absence is available in MyAllina.

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Third Party Authorization Request Form
This Authorization form will allow Allina Health or its authorized representative to share information
about your leave of absence, including medical documentation, benefits and pay with third parties.

To: Allina Health

Date: _______________________________________
Employee Name _______________________________________
Employee ID _______________________________________
Employee Address _______________________________________

I, _______________________________________ hereby authorize Allina health to furnish, provide,

exchange and request information related to my leave of absence to:

Authorized Third Party/Parties

Name of Third Party _______________________________________

Address: _______________________________________
Phone Number: _______________________________________
Email Address: _______________________________________

And I, hereby authorize Allina Health to release, furnish, provide, exchange and request information
related to the leave of absence, including medical documentation, benefits and pay to the Authorized
Third party identified above.

This authorization will remain valid until revoked in writing. You may revoke this authorization at any
time by providing written notice to Allina Health.

I hereby indemnify and forever hold Allina Health harmless from any and all actions and causes of
actions suits, claims, attorney’s fees, or demands against Allina health, which I and/or my heirs may
have resulting from Allina Health discussing or declining to discuss my leave of absence with the above
requestor or person identifying himself/herself to be that requestor, or resulting from provided or
declining to provide any documents or other information concerning the leave of absence to the
requestor.

Signed by: _______________________________________

Signature
_______________________________________
Printed Name
_______________________________________
Date

If you have any questions about the form, please call us at 612-262-4688 or toll free at 1-877-992-8099. TTY/TDD
callers may call the National Relay service at 1-800-855-2880 and request 1-877-992-8099. Form can be faxed to
Allina Health at 612-262-4699.

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