1977 3m dl std-fml ft initial pregnancy pkt

7/25/2019 1977 3M DL STD-FML FT Initial Pregnancy Pkt

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3M Disability Programs PO Box 14431Lexington, KY 40512-4431

August 20, 2015

DIPALI M. PATEL18 FITCHBURG ROAD

AYER, MA 01432


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August 20, 2015

DIPALI M. PATEL18 FITCHBURG ROAD

AYER, MA 01432

RE: Application for Short Term DisabilityClaim Number: 30154446967-0001

Dear DIPALI M. PATEL :

The 3M Disability and Leave Service Center, managed by Sedgwick, is 3Ms administrator for Short TermDisability (STD), Family and Medical Leave Act (FMLA) and leaves required by state law. The 3MDisability and Leave Service Center has been notified of your absence from work due to disability. Youwill need to inform us within 24 48 hours if your return-to-work date changes. If you do not inform us ofthis change, you will be required to provide medical information from your medical provider to supportyour absence. The medical documentation to support your claim is due on or before 09/04/2015.

To be considered for Short Term Disability Benefits, you must be eligible for STD benefits . Failure tomeet the eligibility requirements for Short Term Disability Benefits or failure to timely submit therequired forms may result in delay or denial of benefits.

Required Documents to be completed and returned by 09/04/2015:

1. Authorization for Release of Medical Information and Agreement to Repay DuplicateBenefits. You must sign and date both forms.

2. Attending Provider Statement and Return to Work Assessment: Your treating provider mustcomplete and return these forms.

** Please be advised that your provider may request you to sign their specific release of information formto allow any medical information to be shared with us. Please ask your provider about their policy to helpensure that we get your medical information timely.

Send forms to: 3M Disability and Leave Service CenterPO Box 14431

Lexington, KY 40512-4431PHONE: 1-800-543-5562FAX: 1-800-476-7815

Your benefits may be reduced or terminated (either prospectively or retroactively) if you receive otherincome that includes but is not limited to: work for another employer or self-employment, wagereplacement benefits paid under an insurance policy, any government disability income, etc.

1. If you believe your injury or illness is caused or aggravated by work , you shouldimmediately report it to your manager/supervisor/team leader and the Occupational HealthNurse/Disability Contact to complete a First Report of Injury or Illness.


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!C19120571.338-1977!

2. If your injury or illness was the result of a third party injury (for example a motor vehicleaccident, a slip and fall not on your premises, or you are injured using a machine or otherequipment), your claim will be reviewed for disability subrogation.

At any time 3M Disability may require you to submit additional information in support of yourcontinued disability. This may include an Attending Physician Statement with objective medicalinformation supporting your disability.

Reasonable Accommodations

3M is committed to providing reasonable accommodations to help otherwise qualified employees with adisability perform their essential job functions. If you feel you are an individual that has a physical ormental impairment that substantially limits one or more major life activities who could perform theessential functions of your job with or without a reasonable accommodation, you may be eligible for aworkplace accommodation.

For more information on your Short Term Disability benefits, please refer to the Short Term DisabilitySummary Plan Description, which can be found on 3M Source. Regardless of the benefits permittedunder this disability plan, 3M employees must comply with all other policies, including call-in proceduresand attendance policies in their department or at their location.

3M recognizes that this may be a difficult time for you and your family. For this reason, support servicesare available to employees who are unable to work because of a medical condition or other personalsituation. The enclosed Additional Resources outlines some of the services that may assist you or yourfamily members. If you have questions, require additional information, or experience a change in yourcircumstances, please contact 3M Disability and Leave Service Center Monday through Friday 7:30 a.m.

5:00 p.m. Central Time. Information regarding the status of your leave request can be obtained 24ho urs a day, 7 days a week through our viaOne voice interactive voice response (IVR) system at 1-800-543-5562.

Sincerely,

Chris FjeldSTD Specialist

Toll Free Telephone: 1-800-543-5562, push 0 then Ext. 72Fax: 1-800-476-7815


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!C19120571.338-1977!

3M Disability Programs Please fax back to 1-800-476-7815 AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

Employees Name (Last, First, MI)PATEL, DIPALI M.

Employee ID Number01436093

Claim Number30154446967-0001

I, ____________________________, hereby authorize the representatives and agents of the 3M Disability and WorkersCompensation Programs, including Sedgwick Claims Management Services, Inc. ("Sedgwick CMS") and any of their designatedlegal representatives, counselors, or medical management team, to obtain from any health care provider, insurance company,employer (including 3M Company or 3M affiliate), government agency, benefit plan administrator, benefit plan or program, orrelated party any information concerning advice, care, payments, or treatment provided to me, information regarding the illness orinjury for which I am seeking benefits, or other information relating to my claim for disability or workers compensation ben efits ormy request for reasonable accommodation. This authorization applies to all medical, health, psychological and/or psychiatricinformation, records and reports, including information regarding mental health and substance abuse.

I specifically authorize physicians, nurses and hospitals to communicate my medical or health information by any means, includingwritten or telephonic communications or by direct interview, whether or not I am present during, or notified of, such

communications, and I hereby authori ze the 3M Disability and Workers Compensation Programs, including Sedgwick CMS, toinitiate and conduct such communications whether or not I am present or have received notice of such communications.

I further authorize the representatives and agents of 3M Disability and Workers Compensation Programs, 3M OccupationalMedicine (including occupational health nurses), 3M Company and 3M benefit plans and programs to release to each otheror third parties any information secured by this authorization to evaluate my claim, return to work, or request foraccommodation, or to coordinate my care and/or benefits. I also authorize 3M Company to provide the representativesand agents of the 3M Disability and Workers Compensation Programs with financial or employment-related informationrelevant to my claim for disability or workers compensation benefits or my request for reasonable accommodation.Sedgwick CMS may use my information obtained pursuant to this authorization in any other claim matter that SedgwickCMS may administer or handle related to me.

I understand and give my consent that the information obtained pursuant to this Authorization may be used and disclosed by thereceiving entity without further authorization. I further understand that this Authoriza tion does not limit the receiving entitys ability touse or disclose my information for any purpose required or permitted by the law.

I understand that I may revoke this authorization at any time in writing to 3M Disability Programs Administrator, 3M Center, PO Box14431, Lexington, KY 40512-4431, but any revocation will not apply to disclosures occurring or actions taken prior to the date therevocation is received.

I understand that this Authorization is generally necessary for the processing of my claim or request for reasonableaccommodation. Failure to sign this Authorization or revocation of my authorization may impair or impede the processing of myclaim or request for reasonable accommodation.

By signing below, I represent that any information provided by me or on my behalf is accurate and complete. I understand thatsubmitting false information may result in disciplinary action up to and including termination of employment from 3M and/ortermination or disqualification of benefits.

Signature of Employee Date

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting orrequiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we areasking that you not provide any genetic information when responding to this request for medical information. "Genetic Information" as defined by GINAincludes 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'sfamily member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or anembryo lawfully held by an individual or family member receiving assistive reproductive services .


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3M Disability Programs Please fax back to 1-800-476-7815

AGREEMENT TO REPAY DUPLICATE BENEFITS

Employees Name (Last, First, MI)

PATEL, DIPALI M.Employee ID Number

01436093

Claim Number30154446967-0001

I, ____________________________, understand that benefits paid to me under a 3M disability plan are notintended to duplicate other benefits or income I and my dependents might receive for the same disability,other than proceeds from private disability insurance.

In the event I receive Social Security benefits, workers compensation benefits, veterans benefits,automobile/personal injury insurance proceeds, no fault automobile insurance, or other wage replacement

benefits, I agree for myself as well as my dependents, heirs, executors, attorneys, representatives,administrators and any other successors to repay 3M the amount by which the Plans overpaid my benefits.This obligation to repay benefits applies, but is not limited, to any overpayment or other offset orreimbursement or subrogation provided for under the terms and conditions of the Plans.

If an overpayment occurs, I agree that I will repay the overpayment amount in the manner and time requiredby 3M. I understand that, if I am unable or refuse to repay the overpayment in the matter and time requiredby 3M, my future disability benefits will be reduced and/or my coverage under a 3M disability plan may beterminated. I hereby authorize 3M to reduce any future disability benefit payments or withhold amounts frommy future payroll checks or unpaid vacation balance, to the extent permitted by the applicable law, until 3Mhas collected the amount of any overpayments.

I agree to allow 3M to make a claim on my behalf for any over-collected Social Security taxes related to anoverpayment. I also agree that I have not made a claim for refund or credit and will not make such a claim inthe future.

I further agree for myself as well as my dependents, heirs, executors, attorneys, representatives,administrators and any other successors to cooperate to secure the enforcement of the subrogation andreimbursement rights the 3M disability plans have against any amounts I receive for an illness or injury forwhich a responsible party is or may be liable. This includes taking no action that prejudices or may prejudicethe subrogation or reimbursement rights of the 3M disability plans. As soon as I become aware of anyclaims for which the 3M disability plans are or may be entitled to asset subrogation or reimbursement rights, Iagree to inform 3M. I further agree to reimburse a 3M disability plan in full in accordance with th e plansprovisions.

I acknowledge that failure to abide by the terms of this agreement and a 3M disability plan may result intermination of coverage under the plan.

Signature of Employee Date


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3M Enfamil New Parent Program Registration Form

Name ________________________________________________________________________

Home Address* ________________________________________________________________

City _____________________________________________ State ________ Zip_____________

3M Address (office location) ______________________________________________________

Mothers email address _________________________________________________

Due Date**______________________

Please mail or email completed form to:

Email: Bridget Weiland, [email protected]

Inter-office mail: 3M Healthy Living Attn: Bridget Weiland, 224-2W-15

US Postal Service: 3M Healthy Living Attn: Bridget Weiland

Bldg. 224-2W-15

St. Paul, MN 55144

FAX: 651.737.3210

For Office Purposes Only:

Bag Sent: _____________

Info Submitted to Mead Johnson: ______________

*Your home address will be used to enroll you in the Enfamil New Beginnings Program and Mead Johnson will not share your personal information

will third party vendors.

** As part of the program, you will receive periodic home mailings that include educational materials, promotional discounts and other resources

which will be customized for you based on the different stages of your pregnancy.
mailto:[email protected]:[email protected]:[email protected]:[email protected]


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August 20, 2015

Dipali M Patel 18 fitchburg roadayer, MA 01432

RE: Notice of Family Medical Leave Eligibility and Rights & ResponsibilitiesClaim Number: 30154446967-0001

Dear Dipali M Patel:

On August 19, 2015, 3M became aware of your request to take Family Medical Leave beginning on August 14, 2015 due to a serious health condition that makes you unable to perform the essential

functions of your job..

This Notice is to inform you that you:[ X ] In order to determine your eligibility, we are following up to confirm your hours worked and/or

months of service as of your first absence. We will make an eligibility determination within 5 businessdays and will advise you once the determination is made.

If you have any questions, please contact Human Resources or the 3M Disability Claim Administrator at1-800-543-5562.

Part B: Rights and Responsibilities For Taking FMLA LeaveIn addition to the eligibility requirements in Section A above, you must also do the following:

1) For leave due to a family member injured in the line of duty, please have the Health CareProvider Form for Servicemember completed and returned within 15 calendar days from the dateof this letter. This certification must be completed by a United States Department of Defense(DOD) health care provider, a United States Department of Vetera n Affairs health care provider,a DOD TRICARE network authorized private health care provider, or a DOD non-networkTRICARE authorized private health care provider

2) For an exigency leave request, complete and submit the enclosed certification form and providemilitary orders reflecting the call to active duty, within 15 calendar days from the date of this letter.

3) For all other leave requests, have a Health Care Provider complete the enclosed MedicalCertification Form and return the completed certification within 15 calendar days from the date ofthis letter.

In order for us to determine whether your absence qualifies as FMLA leave, you must provide us

sufficient certification to support your request for FMLA leave no later than 09/04/2015 and yourleave request will remain in a pending status until receipt of a full and complete certification thatsufficiently supports your need for FMLA . If you do not submit the full and complete documentationwithin the required time frame, your FMLA request may be denied. Once a full and completedcertification form and/or military orders are received, you will be notified within 5 business days of theapproval or denial of your FMLA request.

Please return your completed documentation via fax or to the address below. Keep a copy for your fileand send the original to:

3M Disability Programs


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!C19120571.338-1977!

P.O. Box 14431Lexington, KY 40512-4431

Phone: 1-800-543-5562Fax: 1-800-476-7815

If your leave is approved as FMLA leave: If you are on an intermittent Family Medical Leave, your health care premiums will continue to be

deducted from your 3M paychecks. If you are on an unpaid continuous Family Medical leave lasting more than 10 consecutive

workdays, you may continue or decline your group health coverage under the same terms as anactive employee. If you elect to continue coverage, you must pay the portion of the premium thatis normally deducted from your paycheck.

If absence is for your own serious health condition and the absence is eligible under theapplicable disability leave policy (including, but not limited to, Short Term Disability, Sickness and

Accident or Voluntary Plan) the paid leave and unpaid Family Medical Leave will run concurrently. You may be required to furnish 3M with periodic reports of your status and intent to return to work

upon request. Before you are permitted to return to work following your leave, you may be required to present a

return to work slip from your health care provider. For intermittent leave, you will be required to report all intermittent absences on the Absence

Reporting Line in addition to following the regular call-in process required at your work location:o Absences can be reported by calling 1-800-543-5562 and selecting the Add More Time

Option.o Absences must be reported within 5 calendar days of the absence or the absence may

be denied FMLAo Once an intermittent absence is reported on an approved leave, it will be reviewed and

you will be contacted within 2 business days if additional information is needed or theabsence cannot be designated as FMLA.

For continuous leaves, if the circumstances of your leave change and you are able to return towork earlier than the date indicated in this letter, you will be required to notify your assigned casemanager as soon as possible.

If the circumstances of your leave changes, and you are able to return to work earlier than thedate you indicated, you will be required to notify Sedgwick and your manager at least twoworkdays prior to the date you intend to report for work.

If your leave is approved as FMLA leave you will have the following rights while on FMLA leave:

You have the right under the FMLA for up to 12 weeks of unpaid FMLA leave in a 12-month periodcalculated as a rolling 12 month period measured backward from the date of any FMLA leaveusage.

Your health benefits must be maintained during any period of unpaid FMLA leave under the sameterms and conditions as if you continued to work.

You must be reinstated to the same or an equivalent job with the same pay, benefits and terms andconditions of employment on your return from FMLA-protected leave. (If your leave extends beyondthe end of your FMLA entitlement, you do not have return rights under FMLA.)

If you do not return to work following FMLA leave for a reason other than: 1) the continuation,recurrence, or onset of a serious health condition which would entitle you to FMLA leave; 2) thecontinuation, recurrence, or onset of a serious health condition of a covered Servicemembers seriousinjury or illness which would entitle you to FMLA leave; or 3) other circumstances beyond yourcontrol, you may be required to reimburse us for our share of health insurance premiums paid on yourbehalf during your FMLA leave.

Once we obtain the information from you as specified above, we will inform you, within 5 businessdays, of the status of your request for leave and whether your leave will be designated as leaveand count towards your leave entitlement.


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If your absence is due to your own medical condition and lasts greater than 3 consecutive scheduledworkdays, please call your case manager who will advise you of the requirement s under 3Ms disabilitypolicy.

If you believe you have an injury or illness that is caused or aggravated by work, you should immediatelyreport it to your manager/supervisor/team leader and the Occupational Health Nurse/Disability Contact tocomplete a First Report of Injury or Illness.

Medical information you have shared is considered confidential under the Family/Medical Leave Act and

the Americans with Disabilities Act (ADA). Return-to-work information (e.g., restrictions) will be shared ona need to know basis.

3M recognizes that this may be a difficult time for you and your family. For this reason, support servicesare available to employees who are unable to work because of a medical condition or other personalsituation. The enclosed Additional Resources outlines some of the services that may assist you or yourfamily members.

If you have questions regarding this notice, or if your medical condition or return-to-work plans change,please contact me. We thank you for your cooperation.

Sincerely,

Chris FjeldFMLA SpecialistPhone: 651-737-8705Toll Free Telephone: 1-800-543-5562, push 0 then Ext. 72Fax: 651-737-0066 or 1-800-476-7815


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Short Term Disability Reporting Linef o r 3 M

.

Your claim information is now accessible at any time with viaOne voice, a speech-activated self-service system providing 3Memployees a fast and convenient way to receive detailed claim information.

When calling, be sure to have last four digits of your social security number and your date of birth ready to verify your

identity.

The Short Term Disability Reporting Line is available 24 hours a day, 7 days a week at: 800-543-5562, select Option 2, then 2.

Accessing viaOne voice

Obtaining your claim information is fast, easy andsecure.

When prompted, choose from the following options:

If youre calling about a claim you already filed withus, even recently, say Existing Claim.

To submit a claim, say New Claim. After verifyingyour identity, you will be transferred to a ServiceCenter Representative. Be sure to have thephysicians name, phone number and fax numberhandy to expedite the handling of your claim.

To get our mailing address or fax number, say

Contact Information.

Calling about an existing claim?

Allow one business day for processing your new claimbefore obtaining status through this automated system.

Be sure to have the following information ready when

you call; well need it to verify your identity:

Last 4 digits of your SS # and Date of Birth

Existing Claim - Available Claim Information

Once authenticated, you can hear:

the status of your most current short termdisability claim

the last medical update received and whenthe next medical report is due

your return to work date

status of your concurrent leave (if applicable)

approved leave start/end dates

denied leave status and reason for shortterm disability claim

other open claims or claims closed within thelast six months

Need help with additional questions?

To get additional assistance or speak with aService Center Representative, say Agent or press 0 (zero) .

01-01-2014 Copyright 2014 Sedgwick


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Dear Provider:

The 3M Disability and Leave Service Center provides income to employees when they have medical conditionsincluding behavioral health disorders, which prevent them from performing the material duties of their 3Mposition. Under the 3M Disability Plan, employees have the responsibility to ensure that the necessaryinformation is forwarded by their treating physicians/providers to the 3M Disability and Leave Service Centerwithin the required time frame. The following are needed to clarify when employees are considered unable toperform at work due to mental disorders:

Psychiatric Diagnoses, Functional Impairment, Mental Status Exam Psychiatric diagnosis or diagnoses;

How the disorder(s) impairs the employees ability to perform their job. Specific psychiatric signs and symptoms that support the diagnosis(es) and impair the employeesability to perform their job.

Treatment Plan Include treatments you personally provide and those you recommend the employee receive from

other professionals, including psychotropic medications and dosages, psychotherapy, intensiveoutpatient treatment programs, partial hospitalization, and/or in-patient treatment.

Return to Work Plan and Accommodations Restricted or light duty, e.g., 4 hours a day, lifting limits, etc., is often available at worksites for

gradual workplace re-entry, which can be advanced typically over several weeks. Employees returning to work are encouraged to contact the 3M Employee Assistance Program

(EAP), at 1-877-321-7252, which offers confidential consultations that help with workplace re-entry,

workplace conflict, assistance in finding local mental health providers, finding resources, legal orfinancial issues, etc. Note: 3M EAP professionals do not provide therapy or determine eligibility for disability.

On behalf of the employee, I want to thank you for taking the time to complete this form. Please feel free tocontact me.

Sincerely,

Chris Fjeld

LOA RepresentativeToll Free Phone: 1-800-543-5562 press 0 then Ext. 72Fax: 1-800-476-7815


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Employee Name: DIPALI M. PATELClaim Number: 30154446967-0001Medical Due Date: 09/04/15

ATTENDING PROVIDER STATEMENTTo Be Completed by Provider (Please Type or Print)

3M Disability and Leave Service Center , P.O. Box 14431, Lexington, KY 40512-4431Telephone: 800-543-5562 Facsimile: 800-476-7815

1. Patients Name: DIPALI M. PATEL Date of Birth: 08/30/1988

2. Objective findings: HT: WT: BP: TEMP: PULSE: RESP:

3. Patients Complaints:

4. Your Diagnosis: (list all disabling diagnoses including all ICD9 codes)

Primary: ICD9 Code: _______________ Description:

Secondary: ICD9 Code: _______________ Description:

ICD9 Code: _______________ Description:

5. Describe objective/clinical findings to warrant disability, including severity and duration based on the patients presentation

during office visits.

6. 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 _____/_____/_____

7. 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:

8. If patient is pregnant, indicate estimated date of delivery _____/_____/_____

9. Is a C-Section planned? Yes No If so what is the date of the planned C-Section? _____/_____/_____

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):


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Employee Name: DIPALI M. PATELClaim Number: 30154446967-0001

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.

14. List specific functional limitations of Activities of Daily Living (ADLs):

15. Has patient been given any driving restrictions for this disability period? Yes No

If yes please describe:

16. Based on your personal knowledge and treatment, how long has the patient been totally disabled by this sickness and

prevented from working? From _____/_____/_____ to and including _____/_____/_____

17. Has the patient recovered sufficiently to return to work? Yes No

If Yes, give the date th e 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. _____/_____/_____

18. 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.

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II fromrequesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law.To comply with this law, we are asking that you not provide any genetic information when responding to this request for medicalinformation. Genetic information, as defined by GINA, includes an individuals family medical history, the results of an individuals orfamily members genetic tests, the fact that an individual or an individuals family member sought or received genetic servic es, andgenetic information of a fetus carrie d by an individual or an individuals family member or an embryo lawfully held by an individual orfamily member receiving assistive reproductive services.

Telephone Number: Physician Printed Name:

Fax Number: Physician Specialty:

Date Completed: Physician Signature:


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Assessment for Restricted Return to WorkTo Be Completed by Provider (Please Type or Print)

3M Disability and Leave Service Center, P.O. Box 14431, Lexington, KY 40512-4431Telephone: 800-543-5562 Facsimile: 800-476-7815

Employee: DIPALI M. PATELClaim #: 30154446967-0001Date of Birth: 08/30/1988

The patient is released to work with the following restrictions effective: _____/_____/_____Restrictions are effective through: _____/_____/_____Return to work full duty without restrictions effective: _____/_____/_____Will treating provider allow restrictions to be lifted without an addition exam? Yes No If no, please provide date of exam in which reevaluation will take place: _____/_____/_____Has there been a recent failed return to work? Yes No If yes, please indicate when and describe circumstances:

In an 8 hour day, indicate the amount of weight in pounds thatthe patient can: Never

0.5 - 2.5 hrs 1-33%

Occasionally

2.6-5 hrs34-66%

Frequently

5.1-8 hrs67-100%

ContinuouslyLift/Carry lbs lbs lbs lbsPush/Pull lbs lbs lbs lbs

Indicate (by an "X") whether the patient can: Bend/Stoop/CrouchClimbBalanceTwist Upper BodyReach At Shoulder LevelReach Above Shoulder LevelSquat/KneelUse hands repetitivelyUse vibrating tools/equipmentFlex/extend neckKeyboard R handKeyboard L handMouseSpeakHand use: power grip/grasp/turnOther (please list):

If the employer has work available that does not exceed the functional thresholds listed above, the patient can:

Sit up to _____ hours/day Stand up to _____hours/day Walk up to _____ hours/day

Needs intermittent opportunity to: Sit Stand Walk

Needs frequent bathroom breaks Duration and frequency:

Additional Limitations/Recommendations (e.g., environmental conditions, operating equipment, etc.):

Telephone Number: Physician Printed Name:

Fax Number: Physician Specialty:

Date Completed: Physician Signature:


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3M Disability Programs

ADDITIONAL RESOURCES

In addition to your local Human Resource Manager or Occupational Health Nurse, 3M has made thefollowing support services available to assist you and your family in managing your health and theimpact of serious medical conditions. We encourage you to access these services both during yourperiod of disability and after you have recovered.

3M EMPLOYEE ASSISTANCE PROGRAM (EAP) Contact your local 3M EAPProfessional or Call 1-877-321-7252

3M EAP professionals offer confidential Personal Consultation at no cost to help employeesand their families manage a wide range of personal, family, or work place issues. Think ofthem as consultants to you about challenges that impact you, your family or your work. 3MEAP professionals do not provide psychotherapy or treatment, nor do they decide when youare ready to return to work. For employees with serious illnesses or injuries, or on disability,EAP professionals commonly provide confidential consultation about topics such as:

Personal and family adjustment to serious health conditions Managing family and care giving responsibilities Strategies for addressing work issues Discomfort about returning to work Coaching on how to get the most out of psychotherapy or treatment from your

outside provider Managing behavioral health conditions

Health Management Programs

If you are a member of a 3M health plan (Blue Cross and Blue Shield or HealthPartners),depending on your medical condition, your 3M health plan may have a program(s) availableto assist you with your medical condition(s). After a review of your medical condition, alongwith your permission, your 3M Disability Case Manager may refer you to a program withinyour health plan. To obtain additional information regarding this, please contact your healthplan:

Blue Cross and Blue Shield: 1-800-858-0722

HealthPartners: 1-800-255-1886


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Release of Information Provider Consent FormFamily Medical Leave

Medical Release: I authorize my Health Care Provider to release the information requested for claim number _______________ to Sedgwick and my employer and its affiliates for purposes of the evaluation of my familyand medical leave request (including federal Family and Medical Leave Act and/or similar state laws).

I understand that my family and medical leave may be delayed or denied if the information requested on the Certification isnot provided, is unclear, or is incomplete. I understand that I have the right to revoke this authorization in writing at any timeby notifying Sedgwick in writing at:

3M Disability ProgramsPO Box 14431

Lexington, KY 40512-4431

and that if I do not, the authorization will remain in effect until the end of any FMLA leave granted by my employer for claimnumber: ___________________ or the date on which my FMLA leave request is denied, whichever is applicable. Iunderstand that any revocation by me shall not apply to any persons actions taken based on this authorization prior to their receipt of my written revocation and that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by privacy regulations of the U.S. Health and Human Services (65 CFRParts 160 and 164.) A copy of this authorization is as valid as the original.

Clarification and Authentication: I further authorize my Health Care Provider to speak with a representative from the 3MDisability Claim Administrator in order to clarify and authenticate the information on Attending Provider Statement submittedfor claim number___________________ for purposes of the evaluation of my family and medical leave request (includingfederal Family and Medical Leave Act and/or similar state laws).

I understand that I am not required to provide this authorization but that if clarification or authentication is necessary and Ifail to sign below, my family and medical leave may be delayed or denied. I understand that this authorization is subject tothe same terms and conditions regarding revocation, re-disclosure, and validity of copies as the release immediately abovethis one.

Employee Name (please print): ______________________________

SIGNATURE OF EMPLOYEE: _______________________________DATE: ___________

Employee Number: _________________

MEDICAL PROVIDER NAME: __________________________ Phone: ________________ Fax: ______________

If leave is for care of a family member, please complete and have your family member sign the section below:

Family Member Name (please print): ______________________________

SIGNATURE OF FAMILY MEMBER: _____________________________ DATE: __________ (If applicable)

MEDICAL PROVIDER NAME: __________________________ Phone: ________________ Fax: ____________

Employee Name (please print): ______________________________

Employee Signature: _______________________________________ Date: ___________

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting orrequiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we areasking that you not provide any genetic information when responding to this request for medical information. "Genetic Information" as defined by GINAincludes 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'sfamily member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or anembryo lawfully held by an individual or family member receiving assistive reproductive services.

Notwithstanding the foregoing, family medical history may be provided when FMLA caregiver leave is requested to care for a family member, as long asthe family medical history is limited to information needed to substantiate the serious health condition of the family member to be cared for. (Dec 2010)