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Click ‘Get Form’ to open it in the editor.
Begin by entering the Policy/Certificate Number at the top of the form. This is essential for identifying your claim.
In the Medical Information Authority section, provide your authorization by signing and dating where indicated.
Fill in the patient's name, employee's company name, and medical establishment details in the designated fields.
Indicate the nature of admission (Out-patient, In-patient, Day Surgery) and specify the period of admission with start and end dates.
Detail the diagnosis of illness or extent of injury thoroughly in the provided space.
Answer all subsequent questions regarding symptoms, consultations, and treatment history accurately to ensure a comprehensive medical overview.
Finally, have the doctor sign off on the form, including their name, address of clinic/hospital, and date before submission.

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What documentation is needed for CFRA?

The CFRA certification shall be sufficient if it includes all of the following: The date on which the serious health condition commenced. The probable duration of the condition. A statement that, due to the serious health condition, the employee is unable to perform the function of his or her position.

Is there a CFRA form?

Provide this form if youre an employer covered by the federal Family and Medical Leave Act (FMLA) or the California Family Rights Act (CFRA) and either an employee has requested a leave of absence or you recognize the need.

What is a CFRA certification?

Under FMLA (Family Medical Leave Act) and CFRA (California Family Rights Act), the employer may require an employee to submit a certification by the employees health care provider to confirm the existence of the medical condition, qualifying for FMLA or CFRA medical leave.

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What is the difference between WH 380 E and WH 380 F?

WH-380-E Employees Serious Health Condition For when a leave request is due to the medical condition of the employee. WH-380-F Family Members Serious Health Condition For when a leave request is due to the medical condition of the employees family member.

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