Physician or Practitioner Certification (family member) 2026

1. Click ‘Get Form’ to open the Physician or Practitioner Certification in the editor.
2. In Section I, enter the Employee Name and Name of Patient. Specify the Relationship to Employee by selecting from options like Child, Spouse, Parent, or Other.
3. Describe the care you will provide and estimate the leave needed for this care. Ensure to sign and date this section.
4. Move to Section II for completion by the Health Care Provider. Fill in the Provider's name, type of practice, phone number, and fax number.
5. In Part A, provide detailed medical facts regarding the patient's condition. Be specific about symptoms and treatment regimens.
6. Indicate if the condition is pregnancy-related and provide approximate dates for commencement and delivery if applicable.
7. Check relevant categories under FMLA eligibility that apply to the patient’s medical condition.
8. In Part B, check statements that apply regarding the amount of leave needed for care. Provide estimates for intermittent care if necessary.
9. Ensure all sections are completed accurately before signing at the end of Section II. Submit your form as instructed.

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