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 must complete the Medical Leave of Absence Without Pay Application/Extension Form included in this packet. You may also be eligible for a Family ... insurance premiums that McDonalds paid during your leave

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 must complete the Medical Leave of Absence Without Pay Application/Extension Form included in this packet. You may also be eligible for a Family ... insurance premiums that McDonalds paid during your leave

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<ul><li><p>McDonalds Medical Leave of Absence Without Pay </p><p> 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. </p><p>Package 3893 2/6/2007 </p></li><li><p> Package 3893 2/6/2007 </p><p>Checklist </p><p> Read Instructions </p><p> Read Family Medical Leave Information </p><p> Notified Supv. Notified </p><p>Service Center </p><p> Supv. Called Service Center with last day worked </p><p> Completed the form </p><p> Signed and dated the form </p><p> Gave form to Doctor </p><p> Reviewed for completeness &amp; accuracy then mailed or faxed form to the Service Center </p><p> Received Approval/Denial Letter </p><p>McDonalds Medical Leave of Absence without Pay Instructions/Checklist </p><p>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. </p><p>IF YOU NEED ASSISTANCE Contact McDonalds Service Center at 1-877-623-1955. For additional information regarding Leave of </p><p>Absences, see McDonalds Helping Balance Your Work and Life. Si usted tiene preguntas sobre este material, favor de llamar al centro de servicio de </p><p> McDonalds 1-877-623-1955. </p><p>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 </p><p>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. </p><p> 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 </p><p>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. </p><p> Complete the Employee Information section at the top of the form. </p><p> 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 </p><p>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.) </p><p> Mail or Fax the completed form to the McDonalds Service Center. The address and fax number can be </p><p>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 </p><p>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. </p><p> When the Service Center receives the approval or denial from our medical consultants, you will be notified </p><p>with a letter. To continue Medical/Dental/Life Insurance and Healthcare FSA you must have been covered by the benefit </p><p>immediately prior to the Leave Of Absence. You will receive a letter with information about the costs and procedures for continuing your insurance. </p></li><li><p> Package 3893 2/6/2007 </p><p> Filled out Extension Form </p><p> Signed &amp; Dated Form </p><p> Gave form to my Doctor </p><p> Reviewed for completeness &amp; accuracy then mailed or faxed form to the Service Center </p><p> Received Approval/Denial Letter </p><p> Completed Form </p><p> Signed &amp; Dated form </p><p> Reviewed for completeness &amp; accuracy </p><p> Gave form to Doctor </p><p> Gave form to Supervisor </p><p> Mailed or faxed form to the Service Center </p><p> Supv. called Service Center with return to work date </p><p>Next Steps: If you need to continue your leave, complete another MLWOP Application/Extension Form following the </p><p>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 </p><p>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 </p><p>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. </p><p> 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 </p><p>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. </p><p> 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 </p><p>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.) </p><p> Mail or Fax the completed Medical Leave of Absence Without Pay Extension Form to the McDonalds </p><p>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. </p><p> The request for an extension is also subject to approval by both our medical consultants and McDonalds. </p><p>The approval process will take seven to ten business days to review your application, provided that your physician responds in a timely manner. </p><p> When the Service Center receives the approval or denial from our medical consultants, you will be notified </p><p>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 </p><p>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.) </p><p> Provide this signed release form to your direct supervisor and send a copy to the Service Center. You will </p><p>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. </p></li><li><p>Family and Medical Leave Rights and Responsibilities </p><p>MCDONALDS SERVICE CENTER DEPT. 238, MCDONALDS CORPORATION, 2111 MCDONALDS DRIVE, OAK BROOK, IL, 60523 TELEPHONE #: (877) 623-1955 FAX #: (630) 623-5027 5/5/2006 </p><p> Under the McDonalds Family and Medical Leave Policy and consistent with the Federal Family and Medical Leave Act (FMLA) and applicable state law rules, you may qualify for up to 12 weeks of unpaid Family Leave within a 12-month period (Calculation Period) for: 1. The birth of your child, or the placement of a child with you for adoption or foster care; or 2. A serious health condition that makes you unable to perform one or more of the essential functions of your job; or 3. A serious health condition affecting your spouse, child or parent, for which you are needed to provide care. Youre eligible for Family and Medical Leave if youve been employed by McDonalds Corporation at least 12 months and have worked a minimum of 1,250 hours during the 12 months immediately preceding your leave. The 12-month period (Calculation Period) is measured backward from the date your FMLA Leave would begin. This means that for each employee, the 12-month period is a rolling period that is not based on the calendar year. (If you and your spouse or domestic partner both work for McDonalds, you are eligible for a combined 12 weeks off in any 12-month period, except in cases where you need time off because one of you or your child has a serious health condition.) When you return to work from a Family Leave of Absence, you will be placed into your previous position or another equivalent position without any reduction of pay, benefits, or other terms of employment. Failure to return to work at the end of the approved leave period may result in the forfeiture of your right to return to your previous position or another position. Additionally, unless the failure to return to work is due to circumstances beyond your control, you may be required to repay the portion of any health insurance premiums that McDonalds paid during your leave. Please keep in mind the following information: 1. If you do not provide medical certification of a serious health condition within 15 days after you are notified of this requirement, </p><p>such failure may delay the commencement of your leave until the certification is submitted; 2. You may be required, but may not elect, to utilize accrued paid leave concurrently with unpaid FMLA leave; 3. If you currently pay a portion of the premiums for your health insurance, you are responsible for making these payments during </p><p>the period of FMLA Leave. Arrangements for payment will be communicated to you and you will make premium payments accordingly. You must make your premium payments within 30 days of the due date. Otherwise, your group health insurance coverage will cease as of the end of the month for which your last premium payment was made. We will notify you in writing at least 15 days before your insurance coverage will lapse. We will not pay your share of health insurance premiums while you are on leave; refer to What Happens to My Benefits Coverage While on Leave. </p><p>4. You will be required to present a written healthcare providers approval prior to being restored to employment (a Return to Work Form is included in this packet for your convenience). If such certification is required but not received, your return to work may be delayed until the certification is provided. </p><p>5. While on leave, you will be required to furnish us with reports about your situation and intent to return to work periodically. If the circumstances of your leave change and you are able to return to work full or part-time earlier than the date you have indicated, you are required to notify us at least two work days prior to the date you intend to report to work; </p><p>6. You may be required to furnish additional medical information relating to a serious health condition; 7. If you are approved for intermittent or reduced leave schedule, you understand that your pay will be reduced accordingly to reflect </p><p>that such leave is unpaid. </p></li><li><p>Definition of a Licensed Health Care Provider </p><p> The McDonalds Short Term Disability and Medical Leave without Pay programs accept the following as Licensed Health Care Providers (Physician): DC Doctor of Chiropractic DDS Doctor of Dental Surgery DO Doctor of Osteopathic DPM Doctor of Podiatric Medicine MD Medical Doctor OD Optometrist PHD Doctorate in Psychology </p><p> The McDonalds Short Term Disability and Medical Leave without Pay programs DO NOT recognize the employee, the employees spouse, parents or siblings as Health Care providers. Additionally, the McDonalds Short Term Disability and Medical Leave without Pay programs DO NOT recognize the following care providers: </p><p>APRN Advance practice Registered Nurse </p><p>CNM Certified Nurse Midwife </p><p>FNP Family Nurse Practitioner LCSW Licensed Clinical Social Worker M-ED Masters in Education (counselor) MSN Master in Science in Nursing MSW Master of Social Work NP Nurse Practitioner PA-C Physician Assistant - Certified RNC Registered Nurse Clinician </p><p>WHNP Women's Health Nurse Practitioner </p><p> If you have any questions, please contact the McDonalds Service Center at 1-877-623-1955. </p><p>...</p></li></ul>

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