Filling out the Certification of Your Serious Health Condition form

The following provides step-by-step instructions to complete the PFML form for patients who are applying for medical leave for their own serious health condition. The screenshots provided below may not match if you are using an older version of the form. DFML periodically updates the form to improve its usability; however, past versions of the form will be accepted.
A PDF version of this page is available starting on Page 8 of the Health Care Provider toolkit.

Table of Contents

Section 1: Employee applying for paid medical leave

The employee, your patient, who is applying for paid leave, is responsible for completing Section 1 of the Certification of your Serious Health Condition form.

PFML Medical Form

Section 2: Patient's serious health condition

You, as the health care provider, should complete Section 2 through Section 5.

In Section 2, confirm that your patient has a serious health condition and what criteria apply.

  • Detail your patient's serious health condition, including medical visits, regimen of care, and any other pertinent details.
  • Let us know at least one essential job function the patient is unable to perform due to their condition, such as the  inability to make a decision or perform manual labor.
  • Confirm if the condition is job-related or related to pregnancy or recovery from childbirth.
PFML Medical Form
PFML Medical Form

Section 3: 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 multiple episodes of time off, which may be irregular or unexpected
PFML Medical Form

Section 4: Provider's certification and information

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

PFML Medical Form

Review the form and make sure you sign it before returning it to your patient.

PFML Medical Form

Contact

Phone

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

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

Fraud Reporting Hotline: (857) 366-7201

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

For questions about contributions and exemptions: (617) 466-3950

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

Last updated: November 18, 2022

Help Us Improve Mass.gov with your feedback

Feedback