Certification of Health Care Provider for Family Member s Serious Health Condition under the Family 2025

1. Click ‘Get Form’ to open the Certification of Health Care Provider for Family Member’s Serious Health Condition in the editor.
2. In Section I, enter the employee's name and employer's name, along with the date certification was requested. Ensure you allow at least 15 calendar days for completion.
3. Proceed to Section II where you will provide your family member's name and select their relationship to you. Describe the care you will provide and estimate the amount of leave needed.
4. In Section III, health care providers should fill in their contact information and complete all relevant medical details about the patient’s condition, including treatment needs and duration.
5. Review all sections for accuracy before saving or printing your completed form. Ensure that it is signed where required.

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