Mercyhealth FMLA Leave of Absence & Short-Term Disability Paid Time Off Request Form

Please complete all of the information included on this form to ensure timely processing of your timecard while you are out on a leave of absence.

Partner Name Partner Name * First Last
Partner ID Number *
Partner Phone Number (this number will be used for us to contact you while you are out on leave) Partner Phone Number (this number will be used for us to contact you while you are out on leave) * - ### - ### ####
Email (This email will be used for us to contact you while you are out on leave. If no email is provided, we will send communications to your work email.)
Guardian Leave Number - This number can be found on your eligibility packet from Guardian. *
IMPORTANT: PLEASE READ THE FOLLOWING INFORMATION REGARDING YOUR PAY WHILE YOUR SHORT TERM DISABILITY CLAIM IS PENDING.

Partners will not be paid while their short-term disability benefit is pending to ensure we do not interfere with the ability of the partner to receive short-term disability pay from Guardian. Once short-term disability is approved or denied, the leave team will retro pay any missed non short-term disability pay elected below. If there is an urgent situation and you need to receive pay while short-term disability is pending please send an email to hrloa@mhemail.org. *

IMPORTANT: PLEASE READ THE FOLLOWING INFORMATION REGARDING YOUR PAY WHILE YOUR SHORT TERM DISABILITY CLAIM IS PENDING.

Partners will not be paid while their short-term disability benefit is pending to ensure we do not interfere with the ability of the partner to receive short-term disability pay from Guardian. Once short-term disability is approved or denied, the leave team will retro pay any missed non short-term disability pay elected below. If there is an urgent situation and you need to receive pay while short-term disability is pending please send an email to hrloa@mhemail.org. I acknowledge that I have read the above information.
With an approved short-term disability claim, there may be a benefit waiting period. If you are approved FMLA, you must designate if and how you wish to be paid for the absences during your short-term disability waiting period. If you are not approved FMLA, you will be required to use any available PTO during the short-term disability waiting period. *

With an approved short-term disability claim, there may be a benefit waiting period. If you are approved FMLA, you must designate if and how you wish to be paid for the absences during your short-term disability waiting period. If you are not approved FMLA, you will be required to use any available PTO during the short-term disability waiting period. Paid Sick Leave (PSL) - This is only available to partners who had this bank of hours prior to it being frozen. If you are unsure if you have hours in this bank, please check Kronos or MyHR/HR Vital Link to see all hours available in your time off banks. Paid Time Off (PTO) - Select this option if you wish to be paid using your PTO hours. Some partner groups may not be eligible for PTO. In those cases, other available time off plans may be used. Non-Paid Time (Only available if FMLA is approved or if PTO bank is zero) - Select this option if you wish to be unpaid instead of using your PSL or PTO hours. I would like to do something other than the choices above. (Details of pay being requested are required below.)
With an approved short-term disability claim you will receive 60% of your base pay directly from Guardian. You may elect to supplement the short-term disability using available PSL or PTO hours at 40% in order to receive 100% of your pay. *

With an approved short-term disability claim you will receive 60% of your base pay directly from Guardian. You may elect to supplement the short-term disability using available PSL or PTO hours at 40% in order to receive 100% of your pay. Paid Sick Leave (PSL) - This is only available to partners who had this bank of hours prior to it being frozen. If are unsure if you have hours in this bank, please check Kronos or MyHR/HR Vital Link to see all hours available in your time off banks. Paid Time Off (PTO) - Select this option if you wish to be paid using your PTO hours. Some partner groups may not be eligible for PTO. In those cases, other available time off plans may be used. Non-Paid Time - Select this option if you wish to be unpaid instead of using your PSL or PTO hours. I would like to do something other than the choices above. (Details of pay being requested are required below.)
In some situations, a partner's short-term disability may end prior to their FMLA leave ending. Please select how you would like to be paid during your FMLA time that is not running concurrently with short-term disability. *

In some situations, a partner's short-term disability may end prior to their FMLA leave ending. Please select how you would like to be paid during your FMLA time that is not running concurrently with short-term disability. Paid Sick Leave (PSL) - This is only available to partners who had this bank of hours prior to it being frozen. If you are unsure if you have hours in this bank, please check Kronos or MyHR/HR Vital Link to see all hours available in your time off banks. Paid Time Off (PTO) - Select this option if you wish to be paid using your PTO hours. Some partner groups may not be eligible for PTO. In those cases, other available time off plans may be used. Non-Paid Time (Only available if FMLA is approved or if PTO bank is zero) - Select this option if you wish to be unpaid instead of using your PSL or PTO hours. I would like to do something other than the choices above. (Details of pay being requested are required below.)
I acknowledge that the processing of this form is contingent upon FMLA and short-term disability APPROVAL from Guardian. Draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Important Information

1. Paid Sick Leave (PSL) Entitelment Limitations - This is only available to partners who had this bank of hours prior to it being eliminated. If you are unsure if you have hours in this bank, please check Lawson/Infor to see all hours available in your time off banks.
*2 weeks total of PSL can be used for care of a family member(s) per calendar year
*6 weeks total of PSL can be used for pregnancy/childbirth
*6 weeks total of PSL can be used for paternal and maternal (non-birthing) bonding

2. Order of Operation: If you elect to be paid with PSL and PTO, pay will be drawn from your PSL bank first. Once this bank is depleted, pay will be drawn from your PTO bank if elected.

3. If you are approved the Mercy paid caregiver leave benefit or Mercy paid parental Leave benefit, this benefit will be paid before PSL, PTO, or other time off plans are used.

Mercyhealth FMLA Leave of Absence & Short-Term Disability Paid Time Off Request Form

Mercyhealth FMLA Leave of Absence & Short-Term Disability Paid Time Off Request Form

Important Information