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Download McDonald’s Medical Leave of Absence Without Pay - Medical wOut PaMedical Leave of Absence without Pay Application Form • To apply for a Medical Leave of Absence Without Pay, you

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  • McDonalds Medical Leave of Absence Without Pay

    Enclosed you will find your Medical Leave Of Absence without Pay Package. Included in this package you will find the following: 1. McDonalds Medical Leave of Absence without Pay Instructions/Checklist 2. Family and Medical Leave Rights and Responsibilities 3. Definition of a Licensed Health Care Provider 4. Medical Leave of Absence without Pay Application/Extension Form 5. Return to Work Form 6. What Happens to My Benefits Coverage While on Leave 7. Summary of all McDonalds Leaves of Absence Note: The Medical Leave of Absence without Pay will run concurrently with the Family Medical Leave Act. To qualify for Family Medical Leave (FMLA), your treatment does not need to be provided by an approved McDonalds defined Health Care Provider. To qualify for a Family Medical Leave your treatment has to be performed by a FMLA approved Health Care Provider. This would include many additional types of providers such as a Certified Nurse Midwife, Social Worker and Nurse Practitioners, for the definition of a FMLA approved Health Care Provider see enclosed document entitled Definition of a Licensed Health Care Provider, included in your package.

    Package 3893 2/6/2007

  • Package 3893 2/6/2007

    Checklist

    Read Instructions

    Read Family Medical Leave Information

    Notified Supv. Notified

    Service Center

    Supv. Called Service Center with last day worked

    Completed the form

    Signed and dated the form

    Gave form to Doctor

    Reviewed for completeness & accuracy then mailed or faxed form to the Service Center

    Received Approval/Denial Letter

    McDonalds Medical Leave of Absence without Pay Instructions/Checklist

    Instructions/General Information: The following are instructions and a checklist, which will guide you through the Medical Leave of Absence without Pay Process. Read through the instructions to familiarize yourself with the entire process. Then go back and as you complete each required action, check the box on the left. Each box represents an action you need to take.

    IF YOU NEED ASSISTANCE Contact McDonalds Service Center at 1-877-623-1955. For additional information regarding Leave of

    Absences, see McDonalds Helping Balance Your Work and Life. Si usted tiene preguntas sobre este material, favor de llamar al centro de servicio de

    McDonalds 1-877-623-1955.

    A request for a Medical Leave of Absence Without Pay (MLWOP) may also qualify as a request for a Family and Medical Leave, depending upon your eligibility. If you qualify for a Family and Medical Leave, your Medical Leave without pay will run concurrently with your family medical leave. In order for your request to be processed appropriately, it is important that you understand your rights and responsibilities. Refer to the enclosed Family and Medical Leave Rights and Responsibilities sheet, which contains information regarding your rights under the Family and Medical Leave Act of 1993. To get your leave started: Notify your supervisor and the Service Center of your need for a leave. When you stop working, you must remind your supervisor to notify the Service Center of your last day

    worked so that the Service Center can stop your pay to avoid an overpayment. The leave does not begin until your supervisor notifies us of your last day worked. Check with your supervisor to be sure that he/she has notified the Service Center.

    Medical Leave of Absence without Pay Application Form To apply for a Medical Leave of Absence Without Pay, you must complete the Medical Leave of Absence

    Without Pay Application/Extension Form included in this packet. You may also be eligible for a Family Medical Leave of Absence, please contact the Service Center.

    Complete the Employee Information section at the top of the form.

    After reading the Patient Authorization section, sign and date the form. Give the signed form to your physician and have the physician complete the Attending Physician

    Information. The physician should retain a copy for their records and return the completed form to you. (This must be a medical doctor, we do not accept midwives; assistants; nurse practitioners; etc.)

    Mail or Fax the completed form to the McDonalds Service Center. The address and fax number can be

    found at the bottom of your application. Retain a copy of the form for your records. Once your MLWOP application is thoroughly completed we will forward your application to our medical

    consultants. They will review the form, contact your physicians office, and recommend approval or denial of your application. If the leave is approved, they will determine the appropriate length of the leave. McDonalds reserves the right of final approval on all medical claims. Generally, the approval process will take seven to ten business days to review your application, provided your physician responds in a timely manner.

    When the Service Center receives the approval or denial from our medical consultants, you will be notified

    with a letter. To continue Medical/Dental/Life Insurance and Healthcare FSA you must have been covered by the benefit

    immediately prior to the Leave Of Absence. You will receive a letter with information about the costs and procedures for continuing your insurance.

  • Package 3893 2/6/2007

    Filled out Extension Form

    Signed & Dated Form

    Gave form to my Doctor

    Reviewed for completeness & accuracy then mailed or faxed form to the Service Center

    Received Approval/Denial Letter

    Completed Form

    Signed & Dated form

    Reviewed for completeness & accuracy

    Gave form to Doctor

    Gave form to Supervisor

    Mailed or faxed form to the Service Center

    Supv. called Service Center with return to work date

    Next Steps: If you need to continue your leave, complete another MLWOP Application/Extension Form following the

    instructions below to apply for extension of benefits. You may be eligible for Long Term Disability benefits if you are disabled for more than 180 consecutive

    days. Please contact the Service Center for additional information. If you are not eligible for Long Term Disability you will need to continue to apply for a Medical Leave of

    Absence Without Pay. As long as you are approved, you may be on a Short Term Disability or Medical Leave of Absence Without Pay for up to 30 months.

    If you do not need to continue your leave, please go to the Return to Work section. MEDICAL LEAVE WITHOUT PAY APPLICATION/EXTENSION FORM: (Extension) If you are out on an approved MLWOP and are unable to return to work by the expected date, you must

    complete a Medical Leave of Absence Without Pay Application/ Extension Form. An additional copy of the Medical Leave of Absence Without Pay Application/ Extension Form is available through the Service Center Fax-Back system, which can be accessed by calling 1-877-623-1955. The Form # is 3882.

    After reading the Patient Authorization section, sign and date the form. Give the signed form to your physician and have your physician complete the Attending Physician

    Information. The physician should retain a copy for their records and return the completed form to you. (This must be a medical doctor, we do not accept midwives; assistants; nurse practitioners; etc.)

    Mail or Fax the completed Medical Leave of Absence Without Pay Extension Form to the McDonalds

    Service Center. The address and fax number can be found at the bottom of your MLWOP Application Form. Retain a copy of the form for your records.

    The request for an extension is also subject to approval by both our medical consultants and McDonalds.

    The approval process will take seven to ten business days to review your application, provided that your physician responds in a timely manner.

    When the Service Center receives the approval or denial from our medical consultants, you will be notified

    with a letter. Next Step: Go to Return to Work. RETURN TO WORK FORM: If you have been out on a leave due to your own medical condition, you must have an authorized Return to Work Form before you will be allowed to come back to work. Complete the Employee Information portion of the McDonalds Return to Work Form. After reading the Employee Authorization section, sign and date the form. Give the signed form to your physician and have them complete the Attending Physician Information. The

    physician should retain a copy for their records and return the completed form to you. (This must be a medical doctor, we do not accept midwives; assistants; nurse practitioners; etc.)

    Provide this signed release form to your direct supervisor and send a copy to the Service Center. You will

    not be allowed to return to active work until your supervisor receives a signed release. It is your responsibility to remind your supervisor to notify the Service Center of your return to work date and any restriction information. Your pay may be impacted if your return to work date is not called in by your supervisor. You may wish to double check to insure this has occurred.

  • Family and Medical Leave

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