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Fmla medical certification form

Form I - Non FMLA Certification - Family Members Health Condition 2026

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The document is a Non-FMLA Certification of Health Care Provider form designed for employees seeking leave to care for a family member with a serious health condition. It includes sections for the employer, employee, and health care provider to complete, detailing the relationship between the employee and the family member, the nature of care required, and medical information regarding the family member's condition. The form emphasizes compliance with the Genetic Information Nondiscrimination Act (GINA) by prohibiting the inclusion of genetic information.

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Click ‘Get Form’ to open it in the editor.
In Section II, enter your name and the name of the family member you will care for. Specify your relationship and, if applicable, their date of birth.
Describe the care you will provide and estimate the leave needed. Be detailed to ensure clarity.
Sign and date the form at the bottom of Section II before passing it to your family member's health care provider.
In Section III, ensure that the health care provider fills out all relevant medical information, including treatment dates and necessary care details.
Review all sections for completeness before submitting. Make sure all signatures are present.

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Versions	Form popularity	Fillable & printable
2023	4.3 Satisfied (27 Votes)
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non fmla medical certification form

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