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Download a Certification of a Serious Health Condition form

You will need a certification form as part of your application for paid family or medical leave.

Department of Family and Medical Leave

Phone

Department of Family and Medical Leave - Hours of operation: Monday-Friday, 8 a.m - 5 p.m.

Department of Family and Medical Leave - Hours of operation: Monday-Friday, 8 a.m - 5 p.m.

Department of Revenue - Hours of operation: Monday-Friday, 9 a.m. - 4 p.m.

The Details of Download a Certification of a Serious Health Condition form

What you need for 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.

How to download Download a Certification of a Serious Health Condition form

Download the form here and upload it to your leave application.

Downloads for Download a Certification of a Serious Health Condition form

Contact for Download a Certification of a Serious Health Condition form

Phone

Department of Family and Medical Leave - Hours of operation: Monday-Friday, 8 a.m - 5 p.m.

Department of Family and Medical Leave - Hours of operation: Monday-Friday, 8 a.m - 5 p.m.

Department of Revenue - Hours of operation: Monday-Friday, 9 a.m. - 4 p.m.

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