Download a Certification of a Serious Health Condition form

Massachusetts workers can apply for:

• Medical leave due to your own serious health condition

• Family leave to care for a family member with a serious health condition that relates to military service

• Family leave to care for a family member with a serious health condition (starting July 1, 2021)

If you’re applying for paid leave for any of these reasons, you’ll need to complete a Certification of a Serious Health Condition form with a healthcare provider as part of your application. You can begin your application first, or wait until this form is completed.

You do not need a certification of a serious health condition form to apply for family leave to bond with a child or for family leave to manage family affairs when a family member is deployed in a foreign country.

Complete sections 1 and 2 to tell us about your reason for taking leave.

• List your name at the top of each page and in section 1. If you’re applying for family leave, your healthcare provider should list your family member’s name in section 2.

Ask your healthcare provider to complete sections 3–6. Your claim will be delayed or denied without certification from a healthcare provider.