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Application for a full license using FCVS. The physician certification and recertification statements are retained in the hospital's file where they are available for verification if needed.If the employee fails to provide complete and sufficient medical certification, his or her FMLA leave request may be denied. 29 C.F.R. § 825.313. Information. Am qualified to complete this form because: Physician's Full Name (please print legibly). Physician Certification Form. The physician certification and recertification statements are retained in the hospital's file where they are available for verification if needed. Am qualified to complete this form because: Physician's Full Name (please print legibly). I physically examined . Date. If a licensed physician certifying an individual, complete Part 1.