Mercyhealth Leave of Absence 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 your leave) Partner Phone Number (this number will be used for us to contact you while you are out on your leave) * - ### - ### ####
Leave Number (this number starts with AC-) *
Please select the appropriate option below. *
With an approved FMLA leave, you must designate if and how you wish to be paid for all approved absences relating to your FMLA leave.

With an approved FMLA leave, you must designate if and how you wish to be paid for all approved absences relating to your FMLA leave. Paid Sick Leave (PSL) - 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 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. Non-paid time - Select this option if you wish to be unpaid instead of using your PSL or PTO hours. Paid Leave Bank (PLB) - Select this option if you wish to be paid using your PLB (and PTO if PTO eligible) hours. Some partner groups may not be eligible for PLB. In those cases, other available time off plans may be used. If PTO eligible, must have PTO available to use PLB hours.
With an approved short term disability claim there may be a benefit waiting period. If you are approved an FMLA leave, you must designate if and how you wish to be paid for absences during your short term disability waiting period.

With an approved short term disability claim there may be a benefit waiting period. If you are approved an FMLA leave, you must designate if and how you wish to be paid for absences during your 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 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. Paid Time Off (PTO) - Select this option if you wish to be paid using your PTO hours. Non-paid time - Select this option if you wish to be unpaid instead of using your PSL or PTO hours. Paid Leave Bank (PLB) - Select this option if you wish to be paid using your PLB (and PTO if PTO eligible) hours. Some partner groups may not be eligible for PLB. In those cases, other available time off plans may be used. If PTO eligible, must have PTO available to use PLB hours.
With an approved short term disability claim, you may elect to supplement the short term disability using available PSL or PTO hours to receive 100% of pay.

With an approved short term disability claim, you may elect to supplement the short term disability using available PSL or PTO hours to receive 100% of pay. Paid Sick Leave (PSL) - 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. Paid Time Off (PTO) - Select this option if you wish to be paid using your PTO hours. Paid Leave Bank (PLB) - Select this option if you wish to be paid using your PLB (and PTO if PTO eligible) hours. Some partner groups may not be eligible for PLB. In those cases, other available time off plans may be used. If PTO eligible, must have PTO available to use PLB hours. I do not want to supplement my short term disability pay.
I acknowledge that the processing of this form is contingent upon FMLA and/or Short Term Disability APPROVAL from The Standard.
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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 do not qualify for an FMLA leave and are approved a Short Term Disability claim, pay during the waiting period will automatically be satisfied from your PTO bank.