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Download a Certification of your Serious Health Condition form

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

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

What you need for Download a Certification of your Serious Health Condition form

This is a newly updated form needed to take medical leave to manage your own serious health condition. If you are already using the old form, you can submit that as part of your application.

You will need to complete a Certification of your Serious Health Condition form with a health care provider as part of your application for medical leave to care for your own serious health condition. You can begin your application first, or wait until this form is completed.

Continuous leave for your own serious health condition

If you are taking continuous leave, you must provide DFML with a Certification of your Serious Health Condition form filled out by you and your health care provider. It is important that your health care provider fill out the form as completely as possible, especially:

  • A statement that you have a serious health condition (Questions 8-10). This is the reason for your leave so make sure to discuss your medical condition with your health care provider. If this section is not filled out properly and completely, it could delay your leave approval.

  • The date on which your serious health condition started (Form Question 11). 

  • The probable duration of your serious health condition (Form Questions 14-16, Part 3A).

  • A certification that you can’t work due to your serious health condition (Form Question 23).

Reduced or intermittent leave for your own serious health condition

If you are taking intermittent or reduced paid leave in addition to continuous or instead of continuous leave, your health care provider should also include the items listed below:

  • The probable duration of your serious health condition (Form Questions 17-19 and/or 20-22, Part 3B and C) 

Once you have filled out your section of the form and had your health care provider fill out their section, you can upload the form to your account, mail it, or fax it as part of your application. 

Learn more about Document Requirements

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

Download the form. 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

Please send copies of the documents. Do not send the Department original documents - they will not be returned to you.

Please write or type your application ID number in the top left corner of each page mailed 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

Download the form. 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 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

Downloads for Download a Certification of your Serious Health Condition form

Contact for Download a Certification of your 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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