Filling out the Certification of Your Family Member's Serious Health Condition form

Instructions for health care providers who need to fill out this Paid Family and Medical Leave (PFML) form for patients who are applying for medical leave to care for a family member with a serious health condition.
A PDF version of this page is available starting on Page 10 of the Health Care Provider toolkit.

Table of Contents

Section 1: Employee applying for family leave to care for a family member

The employee who is applying for paid family leave to care for your patient should complete Section 1 of the Certification of Your Family Member's Serious Health Condition form.

PFML family medical form

Section 2: Family member information

The employee should enter information about their family member, your patient, to complete Section 2.

PFML family medical form

Section 3: Family member's serious health condition

You, as the health care provider, should complete Section 3 through Section 5.

In Section 3, confirm that your patient has a serious health condition and what criteria apply.

  • Confirm if it is related to the patient's military service.
  • Note any relevant medical information about your patient that shows that they will require care.
  • Describe the kinds of care your patient might need.
PFML family medical form

Section 4: Estimate leave details

Provide your best estimate on what type of leave schedule will be needed: continuous, reduced, intermittent, or a combination of the three.

  • Continuous leave: Full-time leave taken without interruptions
  • Reduced leave: Consistent schedule that is less than an employee's regular work schedule
  • Intermittent leave: Leave taken in separate periods of time due to a single qualifying reason
PFML family medical form

Section 5: Provider's certification and information

Provide information on your certification, and area of practice or medical specialty.

Review the form and make sure you have signed it before returning it to the employee.

PFML family medical form

Contact   for Filling out the Certification of Your Family Member's Serious Health Condition form

Phone

Get answers to your questions in English, Español, and Português. Translation services for up to 240+ languages are also available. Call Department of Family and Medical Leave, Get answers to your questions in English, Español, and Português. Translation services for up to 240+ languages are also available. at (833) 344-7365

Department of Family and Medical Leave - Hours of operation: Monday-Friday, 8 a.m. - 4:30 p.m.

Department of Family and Medical Leave - Hours of operation: Monday-Friday, 8 a.m. - 4:30 p.m.

Department of Revenue - Hours of operation: Monday-Friday, 8:30 a.m. - 4:30 p.m.

Last updated: July 11, 2022

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