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

Certification of Health Care Provider for Family Member s Serious Health Condition under the Family 2026

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The document is a certification form from the U.S. Department of Labor's Wage and Hour Division, intended for employees seeking Family and Medical Leave Act (FMLA) leave to care for a family member with a serious health condition. It outlines the requirements for medical certification, including the responsibilities of both the employee and health care provider, and emphasizes the importance of submitting complete and timely information to avoid denial of leave requests.

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Click ‘Get Form’ to open the Certification of Health Care Provider for Family Member’s Serious Health Condition in the editor.
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.
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.
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.
Review all sections for accuracy before saving or printing your completed form. Ensure that it is signed where required.

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Versions	Form popularity	Fillable & printable
2020	4.6 Satisfied (84 Votes)
2015	4.3 Satisfied (50 Votes)
2009	4.4 Satisfied (358 Votes)

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Can you say someone is on FMLA?

As a general rule, an employees health and other information is confidential. Therefore, you should not disclose any confidential information to other employees. However, you may provide general information and you may tell others that an employee is out of the office on a leave of absence.

What to write on FMLA paperwork for family members?

Youll need to know: Their name and relationship to you. The type of care youre providing and how much time off you need.

Who fills out the certification of health care provider?

Either the employee or the employer may complete Section I. While use of this form is optional, this form asks the health care provider for the information necessary for a complete and sufficient medical certification, which is set out at 29 C.F.R. 825.306.

How do you describe the care you will provide to your family member?

Helping the family member with daily tasks they cant do themselves, such as helping them get dressed or preparing meals. Providing transportation to the doctor for appointments and treatment. Helping make arrangements for changes in care, such as a transfer to a nursing home.

What to write on FMLA?

1. FMLA Form WH-380-E for Employee Health Condition When your condition began. The best estimate of how long it can last. Whether the condition has required an overnight stay in a medical facility. The job duties that your condition prevents you from providing. Symptoms, diagnosis, and treatment plan.

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