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INSTRUCTIONS FOR HEALTH CARE PROVIDER: A HEALTH - does

INSTRUCTIONS FOR HEALTH CARE PROVIDER: A HEALTH - does 2026

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The document is a Medical Leave Medical Certification Form (PFL-MMC) used to apply for Medical Leave benefits under the DC Paid Family Leave law. It requires claimants to provide personal information and have their healthcare provider complete sections detailing the patient's serious health condition, including diagnosis, treatment needs, and duration of leave required. The form must be fully completed and signed by a licensed healthcare provider to avoid denial of the claim.

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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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