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INSTRUCTIONS FOR HEALTH CARE PROVIDER: A HEALTH - does 2026
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- Begin by accessing the form through our platform. Click ‘Get Form’ to open it in the editor.
- In Section 1, enter your personal details including your last name, first name, date of birth, and Social Security Number or ITIN. Ensure all fields are accurately filled out.
- Proceed to Section 2, where your licensed health care provider will need to complete Parts A, B, and C. They should provide their information including name, address, and contact details.
- In Part B, the health care provider must specify the qualifying medical condition by entering the diagnosis and relevant ICD-10 codes. They should also check applicable statements regarding your condition.
- Finally, in Part C, they will indicate the amount of leave needed based on continuous incapacity or planned medical treatments. Ensure they sign and date the form before submission.
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