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Download a Certification of your Family Member's Serious Health Condition form

You will need a Certification of your Family Member's Serious Health Condition form as part of your application for family 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, 8:30 a.m. - 4:30 p.m.

The Details of Download a Certification of your Family Member's Serious Health Condition form

What you need for Download a Certification of your Family Member's Serious Health Condition form

This is a new required form for applications for leave to manage your family member’s serious health condition. Prior to applying for this leave, you need to notify your employer of the need for the leave and the nature of your relationship to the person for whom you need to provide care.

This is a different form than the Certification of your Serious Health Condition form used for Medical Leave applications. Submitting the wrong Certification form with your application may delay your application. You can find the Medical Leave form here.

To be approved for paid family leave to care for a family member, we will need to confirm your relationship to your family member and their serious health condition. To do this, you’ll need a Certification of your Family Member's Serious Health Condition form filled out by your family member’s health care provider. It is important that your family member’s health care provider fill out the form completely, providing specific information in response to the questions below:

  • Confirmation that your family member has a serious health condition and any other relevant details about your family member’s condition (Form Questions 14-15, 18). This is the reason for your leave so make sure to have your family member discuss their medical condition with their health care provider. If this section is not filled out properly and completely, it could delay your application.

  • The date on which your family member’s condition began (Form Question 16) 

  • That you, the employee, are needed to care for the family member and what kinds of care might be needed (Form Question 19-20)

  • Information about how often and for how long your family member needs you to care for them (Form Questions 21-29)

  • The name and address of your family member and their relationship to you (Form Questions 8-11) 

Once you have filled out your section of the form and had your family member’s health care provider fill out their section, you can upload, fax, or mail the form as part of your application. Make sure to include all the pages of the form.

Learn more about Document Requirements.

 

How to download Download a Certification of your Family Member's Serious Health Condition form

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

Download the form here. Documents can be mailed to the Department at this address:

Department of Family and Medical Leave  
Attn: Claims Processing 
P.O. Box 838  
Lawrence, MA 01842

Download the form here. Documents can be faxed to the Department at (617) 855-6180, if they are black and white.  We cannot accept color copies by fax at this time.

If you plan to fax your application, please confirm that the application is in the order with all pages numbered in the top right corner. Supporting forms should come after the main application form, followed by all required attachments. 

Again, please write or type your application ID number in the top left corner of each page mailed or faxed to the Department.   

Your application ID is located on all notices you receive from the Department or when you log in to your paid leave account. 

Contact for Download a Certification of your Family Member's 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, 8:30 a.m. - 4:30 p.m.

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