INSTRUCTIONS FOR HEALTH CARE PROVIDER: A HEALTH CARE PROVIDER INFORMATION 2026

1. Begin by accessing the form through our platform. Click ‘Get Form’ to open it in the editor.
2. In Part 1, fill in your personal details including your last name, first name, middle name, date of birth, and phone number. Ensure all fields are accurately completed.
3. Proceed to Part 2, where your licensed health care provider will need to complete Sections A through D. They must provide their information including name, mailing address, telephone number, and medical specialty.
4. For Section B, the health care provider should specify the qualifying medical condition along with relevant ICD-10 codes and any applicable statements regarding treatment or incapacity.
5. In Section C, detail the amount of leave needed by providing dates for continuous or intermittent incapacity as well as planned medical treatments.
6. Finally, ensure that your health care provider signs and dates the certification section to validate the information provided before submitting it online.

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