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Certification of health care provider for family member's serious health condition 2025

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The document is the Certification of Health Care Provider for Family Member's Serious Health Condition (Form WH-380-F), which is used under the Family and Medical Leave Act (FMLA). It outlines the process for employers to require medical certification from employees seeking FMLA leave to care for a family member with a serious health condition. The form includes sections for completion by the employer, employee, and health care provider, detailing necessary information about the family member's condition and the care required.

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Click ‘Get Form’ to open it in the editor.
In Section I, the employer should provide their name and contact information. This section is crucial as it verifies the employer's acknowledgment of the FMLA request.
Move to Section II, where the employee fills in their name, the family member’s name, relationship, and date of birth if applicable. Clearly describe the care needed and estimate the leave required.
In Section III, the health care provider must complete all relevant parts. They should provide medical facts about the condition, including treatment details and expected duration.
Ensure that all sections are filled out completely before submitting. The health care provider must sign and date the form at the end.

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What is a serious health condition under CFRA?

A serious health condition is an illness, injury, impairment, or physical or mental condition that causes or requires: Any period of incapacity or treatment in connection with, or after inpatient care.

Who qualifies for FMLA in Massachusetts?

To qualify for FMLA, an employee must have been with their employer for at least 12 months, with at least 1,250 hours worked over that time. Private sector employers must have over 50 employees to qualify for eligibility. FMLA also applies to all public sector employees and employees in all public and private schools.

What qualifies for FMLA in NC?

FMLA leave is available if an employee needs time off to: recuperate from a serious health condition. care for a family member with a serious health condition. bond with a new child. handle qualifying exigencies arising out of a family member's military service, or.

healthcare certification form

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How do I apply for FMLA in NY?

To apply for leave under FMLA, contact the personnel office of your employer agency. If eligible and approved, the personnel office will provide to the Fund's administrative office the appropriate information for continuation of Fund benefits.

What are considered major medical conditions?

Conditions that are life threatening: (1) cancer, (2) heart disease, (3) stroke, and (4) HIV/AIDS. Conditions that cause serious disability without necessarily being life threatening: (1) stroke, (2) closed head or spinal cord injuries, (3) mental retardation, and (4) congenital malformations.

What is a provider certificate?

The purpose of certification of health care provider is to certify those employees on medical leave who otherwise do not qualify for or have exhausted all time off under the Family and Medical Leave Act (FMLA).

What is covered under OFLA?

Under OFLA, an employee must be allowed to take family leave for any illness or injury of a child that requires home care, although there is no serious health condition. This time cannot be charged against the FMLA leave. OFLA allows you to take up to 2 weeks of leaver for bereavement of a qualifying family member.

Who can be a certificate provider for LPA UK?

Who can be a certificate provider for my LPA? A Certificate Provider must be independent of the application, not related to the donor or attorney(s), over the age of 18 and have known you well for at least two years.