INSTRUCTIONS FOR HEALTH CARE PROVIDER: A HEALTH - does 2025

1. Begin by accessing the form through our platform. Click ‘Get Form’ to open it in the editor.
2. 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.
3. 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.
4. For 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.
5. In Part C, the provider will indicate the amount of leave needed based on continuous incapacity or planned medical treatments. They should provide any additional information that supports your claim.
6. Finally, ensure that your health care provider signs and dates the form before submission to avoid delays in processing your claim.

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