Dp 2496-2026

1. Click ‘Get Form’ to open the dp 2496 in the editor.
2. Begin by entering the employee’s name in the first field. If the patient is different from the employee, fill in their name in the second field.
3. Review the attached sheet for categories of serious health conditions. Check the applicable category that qualifies for the patient's condition.
4. In section four, provide a detailed description of medical facts supporting your certification, ensuring it aligns with one of the categories checked.
5. State the approximate date when the condition began and its expected duration. Indicate if intermittent work is necessary due to this condition.
6. If additional treatments are required, estimate their frequency and duration. Include any necessary details about treatments provided by other healthcare providers.
7. Complete sections regarding whether medical leave is needed for either the employee's own condition or to care for a family member, providing necessary details as prompted.
8. Finally, ensure all signatures are completed at the bottom of the form before saving your changes.

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