3M Disability Programs

PO Box 14431
Lexington, KY 40512-4431

August 20, 2015

DIPALI M. PATEL
18 FITCHBURG ROAD
AYER, MA 01432

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

August 20, 2015

DIPALI M. PATEL
18 FITCHBURG ROAD
AYER, MA 01432

RE:
Application for Short Term Disability
Claim Number: 30154446967-0001
Dear DIPALI M. PATEL :
The 3M Disability and Leave Service Center, managed by Sedgwick, is 3Ms administrator for Short Term
Disability (STD), Family and Medical Leave Act (FMLA) and leaves required by state law. The 3M
Disability and Leave Service Center has been notified of your absence from work due to disability. You
will need to inform us within 24 48 hours if your return-to-work date changes. If you do not inform us of
this change, you will be required to provide medical information from your medical provider to support
your 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 to
meet the eligibility requirements for Short Term Disability Benefits or failure to timely submit the
required 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 Duplicate
Benefits. You must sign and date both forms.
2. Attending Provider Statement and Return to Work Assessment: Your treating provider must
complete and return these forms.

** Please be advised that your provider may request you to sign their specific release of information form
to allow any medical information to be shared with us. Please ask your provider about their policy to help
ensure that we get your medical information timely.
Send forms to:

3M Disability and Leave Service Center

PO Box 14431
Lexington, KY 40512-4431
PHONE: 1-800-543-5562
FAX: 1-800-476-7815

Your benefits may be reduced or terminated (either prospectively or retroactively) if you receive other
income that includes but is not limited to: work for another employer or self-employment, wage
replacement 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 should
immediately report it to your manager/supervisor/team leader and the Occupational Health
Nurse/Disability Contact to complete a First Report of Injury or Illness.

!C19120571.338-1977!

2. If your injury or illness was the result of a third party injury (for example a motor vehicle
accident, a slip and fall not on your premises, or you are injured using a machine or other
equipment), your claim will be reviewed for disability subrogation.
At any time 3M Disability may require you to submit additional information in support of your
continued disability. This may include an Attending Physician Statement with objective medical
information supporting your disability.
Reasonable Accommodations
3M is committed to providing reasonable accommodations to help otherwise qualified employees with a
disability perform their essential job functions. If you feel you are an individual that has a physical or
mental impairment that substantially limits one or more major life activities who could perform the
essential functions of your job with or without a reasonable accommodation, you may be eligible for a
workplace accommodation.
For more information on your Short Term Disability benefits, please refer to the Short Term Disability
Summary Plan Description, which can be found on 3M Source. Regardless of the benefits permitted
under this disability plan, 3M employees must comply with all other policies, including call-in procedures
and 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 services
are available to employees who are unable to work because of a medical condition or other personal
situation. The enclosed Additional Resources outlines some of the services that may assist you or your
family members. If you have questions, require additional information, or experience a change in your
circumstances, 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 24
hours a day, 7 days a week through our viaOne voice interactive voice response (IVR) system at 1-800543-5562.

Sincerely,
Chris Fjeld
STD Specialist
Toll Free Telephone: 1-800-543-5562, push 0 then Ext. 72
Fax: 1-800-476-7815

!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 Number
01436093

Claim Number
30154446967-0001

I, ____________________________, hereby authorize the representatives and agents of the 3M Disability and Workers
Compensation Programs, including Sedgwick Claims Management Services, Inc. ("Sedgwick CMS") and any of their designated
legal 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, or
related party any information concerning advice, care, payments, or treatment provided to me, information regarding the illness or
injury for which I am seeking benefits, or other information relating to my claim for disability or workers compensation benefits or
my request for reasonable accommodation. This authorization applies to all medical, health, psychological and/or psychiatric
information, 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, including
written or telephonic communications or by direct interview, whether or not I am present during, or notified of, such
communications, and I hereby authorize the 3M Disability and Workers Compensation Programs, including Sedgwick CMS, to
initiate 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 Occupational
Medicine (including occupational health nurses), 3M Company and 3M benefit plans and programs to release to each other
or third parties any information secured by this authorization to evaluate my claim, return to work, or request for
accommodation, or to coordinate my care and/or benefits. I also authorize 3M Company to provide the representatives
and agents of the 3M Disability and Workers Compensation Programs with financial or employment-related information
relevant 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 Sedgwick
CMS 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 the
receiving entity without further authorization. I further understand that this Authorization does not limit the receiving entitys ability to
use 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 Box
14431, Lexington, KY 40512-4431, but any revocation will not apply to disclosures occurring or actions taken prior to the date the
revocation is received.
I understand that this Authorization is generally necessary for the processing of my claim or request for reasonable
accommodation. Failure to sign this Authorization or revocation of my authorization may impair or impede the processing of my
claim 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 that
submitting false information may result in disciplinary action up to and including termination of employment from 3M and/or
termination 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 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 medical information. "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.

!C19120571.338-1977!

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 Number
30154446967-0001

I, ____________________________, understand that benefits paid to me under a 3M disability plan are not
intended 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 or
reimbursement 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 required
by 3M. I understand that, if I am unable or refuse to repay the overpayment in the matter and time required
by 3M, my future disability benefits will be reduced and/or my coverage under a 3M disability plan may be
terminated. I hereby authorize 3M to reduce any future disability benefit payments or withhold amounts from
my future payroll checks or unpaid vacation balance, to the extent permitted by the applicable law, until 3M
has 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 an
overpayment. I also agree that I have not made a claim for refund or credit and will not make such a claim in
the 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 and
reimbursement rights the 3M disability plans have against any amounts I receive for an illness or injury for
which a responsible party is or may be liable. This includes taking no action that prejudices or may prejudice
the subrogation or reimbursement rights of the 3M disability plans. As soon as I become aware of any
claims for which the 3M disability plans are or may be entitled to asset subrogation or reimbursement rights, I
agree to inform 3M. I further agree to reimburse a 3M disability plan in full in accordance with the plans
provisions.
I acknowledge that failure to abide by the terms of this agreement and a 3M disability plan may result in
termination of coverage under the plan.
Signature of Employee

!C19120571.338-1977!

Date

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, bweiland@mmm.com
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.

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

August 20, 2015

Dipali M Patel
18 fitchburg road
ayer, MA 01432

RE:

Notice of Family Medical Leave Eligibility and Rights & Responsibilities

Claim 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 business
days and will advise you once the determination is made.
If you have any questions, please contact Human Resources or the 3M Disability Claim Administrator at
1-800-543-5562.
Part B: Rights and Responsibilities For Taking FMLA Leave
In 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 Care
Provider Form for Servicemember completed and returned within 15 calendar days from the date
of this letter. This certification must be completed by a United States Department of Defense
(DOD) health care provider, a United States Department of Veteran Affairs health care provider,
a DOD TRICARE network authorized private health care provider, or a DOD non-network
TRICARE authorized private health care provider
2) For an exigency leave request, complete and submit the enclosed certification form and provide
military 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 Medical
Certification Form and return the completed certification within 15 calendar days from the date of
this 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 your
leave request will remain in a pending status until receipt of a full and complete certification that
sufficiently supports your need for FMLA . If you do not submit the full and complete documentation
within the required time frame, your FMLA request may be denied. Once a full and completed
certification form and/or military orders are received, you will be notified within 5 business days of the
approval or denial of your FMLA request.
Please return your completed documentation via fax or to the address below. Keep a copy for your file
and send the original to:
3M Disability Programs

!C19120571.338-1977!

P.O. Box 14431

Lexington, KY 40512-4431
Phone: 1-800-543-5562
Fax: 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 an
active employee. If you elect to continue coverage, you must pay the portion of the premium that
is normally deducted from your paycheck.
If absence is for your own serious health condition and the absence is eligible under the
applicable 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 FMLA
o 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 the
absence cannot be designated as FMLA.
For continuous leaves, if the circumstances of your leave change and you are able to return to
work earlier than the date indicated in this letter, you will be required to notify your assigned case
manager as soon as possible.
If the circumstances of your leave changes, and you are able to return to work earlier than the
date you indicated, you will be required to notify Sedgwick and your manager at least two
workdays 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 period
calculated as a rolling 12 month period measured backward from the date of any FMLA leave
usage.
Your health benefits must be maintained during any period of unpaid FMLA leave under the same
terms 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 and
conditions of employment on your return from FMLA-protected leave. (If your leave extends beyond
the 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) the
continuation, recurrence, or onset of a serious health condition of a covered Servicemembers serious
injury or illness which would entitle you to FMLA leave; or 3) other circumstances beyond your
control, you may be required to reimburse us for our share of health insurance premiums paid on your
behalf during your FMLA leave.

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

!C19120571.338-1977!

If your absence is due to your own medical condition and lasts greater than 3 consecutive scheduled
workdays, please call your case manager who will advise you of the requirements under 3Ms disability
policy.
If you believe you have an injury or illness that is caused or aggravated by work, you should immediately
report it to your manager/supervisor/team leader and the Occupational Health Nurse/Disability Contact to
complete 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 on
a need to know basis.
3M recognizes that this may be a difficult time for you and your family. For this reason, support services
are available to employees who are unable to work because of a medical condition or other personal
situation. The enclosed Additional Resources outlines some of the services that may assist you or your
family 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 Fjeld
FMLA Specialist
Phone: 651-737-8705
Toll Free Telephone: 1-800-543-5562, push 0 then Ext. 72
Fax: 651-737-0066 or 1-800-476-7815

!C19120571.338-1977!

Short Term Disability Reporting Line

for 3M
Your claim information is now accessible at any time with viaOne voice, a speech-activated self-service system providing 3M
employees 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

Existing Claim - Available Claim Information

Obtaining your claim information is fast, easy and

secure.

Once authenticated, you can hear:

the status of your most current short term

disability claim

When prompted, choose from the following options:

If youre calling about a claim you already filed with

us, even recently, say Existing Claim.

the last medical update received and when

the next medical report is due

To submit a claim, say New Claim. After verifying

your identity, you will be transferred to a Service
Center Representative. Be sure to have the
physicians name, phone number and fax number
handy to expedite the handling of your claim.

your return to work date

status of your concurrent leave (if applicable)

approved leave start/end dates

denied leave status and reason for short

term disability claim

other open claims or claims closed within the

last six months

To get our mailing address or fax number, say

Contact Information.

Calling about an existing claim?

Allow one business day for processing your new claim
before 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

Need help with additional questions?

To get additional assistance or speak with a

Service Center Representative, say Agent
or press 0 (zero).

.
01-01-2014

Copyright 2014 Sedgwick

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

Dear Provider:
The 3M Disability and Leave Service Center provides income to employees when they have medical conditions
including behavioral health disorders, which prevent them from performing the material duties of their 3M
position. Under the 3M Disability Plan, employees have the responsibility to ensure that the necessary
information is forwarded by their treating physicians/providers to the 3M Disability and Leave Service Center
within the required time frame. The following are needed to clarify when employees are considered unable to
perform 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 employees
ability 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, intensive
outpatient 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 or
financial 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 to
contact me.

Sincerely,

Chris Fjeld
LOA Representative
Toll Free Phone: 1-800-543-5562 press 0 then Ext. 72
Fax: 1-800-476-7815

!C19120571.338-1977!

Employee Name:
Claim Number:
Medical Due Date:

DIPALI M. PATEL
30154446967-0001
09/04/15

ATTENDING PROVIDER STATEMENT

To Be Completed by Provider (Please Type or Print)
3M Disability and Leave Service Center, P.O. Box 14431, Lexington, KY 40512-4431
Telephone: 800-543-5562 Facsimile: 800-476-7815

1.

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

2.

Objective findings: HT:

3.

Patients Complaints:

4.

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

Primary:

WT:

BP:

TEMP:

PULSE:

RESP:

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

7.

Dose

Frequency

Duration

Is this condition the result of an injury? Yes

New Med

Adjusted Med

Date Adjusted

Yes

No

Yes

No

_____/_____/_____

Yes

No

Yes

No

_____/_____/_____

Yes

No

Yes

No

_____/_____/_____

Yes

No

Yes

No

_____/_____/_____

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):

!C19120571.338-1977!

Employee Name:
Claim Number:

DIPALI M. PATEL
30154446967-0001

Yes

11. Have there been any Emergency Room visits OR Hospitalizations during this current disability period?
If Yes:

Emergency Room visit Hospitalization

No

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
If Yes, give the date the patient was able to return to work

No

_____/_____/_____

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
If Yes, indicate date restrictions begin: _____/_____/_____

_____/_____/_____

No

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 from
requesting 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 medical
information. Genetic information, as defined by GINA, includes an individuals family medical history, the results of an individuals or
family members genetic tests, the fact that an individual or an individuals family member sought or received genetic services, and
genetic information of a fetus carried by an individual or an individuals family member or an embryo lawfully held by an individual or
family member receiving assistive reproductive services.

Telephone Number:

Physician Printed Name:

Fax Number:

Physician Specialty:

Date Completed:

Physician Signature:

!C19120571.338-1977!

Assessment for Restricted Return to Work

To Be Completed by Provider (Please Type or Print)
3M Disability and Leave Service Center, P.O. Box 14431, Lexington, KY 40512-4431
Telephone: 800-543-5562 Facsimile: 800-476-7815

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

the patient can:

Never

Lift/Carry
Push/Pull
Indicate (by an "X") whether the patient can:
Bend/Stoop/Crouch
Climb
Balance
Twist Upper Body
Reach At Shoulder Level
Reach Above Shoulder Level
Squat/Kneel
Use hands repetitively
Use vibrating tools/equipment
Flex/extend neck
Keyboard R hand
Keyboard L hand
Mouse
Speak
Hand use: power grip/grasp/turn
Other (please list):

lbs
lbs

0.5 - 2.5 hrs 133%

Occasionally
lbs
lbs

2.6-5 hrs
34-66%
Frequently
lbs
lbs

5.1-8 hrs
67-100%
Continuously
lbs
lbs

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

Needs intermittent opportunity to:

Sit Stand Walk

Needs frequent bathroom breaks

Duration and frequency:

Walk up to _____ hours/day

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

Telephone Number:

Physician Printed Name:

Fax Number:

Physician Specialty:

Date Completed:

Physician Signature:

!C19120571.338-1977!

3M Disability Programs
ADDITIONAL RESOURCES

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

3M EMPLOYEE ASSISTANCE PROGRAM (EAP)

Professional or Call 1-877-321-7252

Contact your local 3M EAP

3M EAP professionals offer confidential Personal Consultation at no cost to help employees

and their families manage a wide range of personal, family, or work place issues. Think of
them as consultants to you about challenges that impact you, your family or your work. 3M
EAP professionals do not provide psychotherapy or treatment, nor do they decide when you
are 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) available
to assist you with your medical condition(s). After a review of your medical condition, along
with your permission, your 3M Disability Case Manager may refer you to a program within
your health plan. To obtain additional information regarding this, please contact your health
plan:
Blue Cross and Blue Shield: 1-800-858-0722
HealthPartners: 1-800-255-1886

Release of Information Provider Consent Form

Family 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 family
and 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 is
not provided, is unclear, or is incomplete. I understand that I have the right to revoke this authorization in writing at any time
by notifying Sedgwick in writing at:
3M Disability Programs
PO 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 claim
number: ___________________ or the date on which my FMLA leave request is denied, whichever is applicable. I
understand 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 redisclosure by the recipient and no longer protected by privacy regulations of the U.S. Health and Human Services (65 CFR
Parts 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 3M
Disability Claim Administrator in order to clarify and authenticate the information on Attending Provider Statement submitted
for claim number___________________ for purposes of the evaluation of my family and medical leave request (including
federal 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 I
fail to sign below, my family and medical leave may be delayed or denied. I understand that this authorization is subject to
the same terms and conditions regarding revocation, re-disclosure, and validity of copies as the release immediately above
this 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 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 medical information. "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.
Notwithstanding the foregoing, family medical history may be provided when FMLA caregiver leave is requested to care for a family member, as long as
the family medical history is limited to information needed to substantiate the serious health condition of the family member to be cared for. (Dec 2010)

!C19120571.338-1977!