Certification of Serious Health Condition form

You can download the form on our website here.

The information on the Certification of Serious Health Condition form is required when someone applies for:

• Medical leave due to their own serious health condition
• Medical leave due to their own pregnancy/child’s birth
• Family leave to take care of a family member with a serious health condition

Your patient will complete section one of this form and you will complete section two. You must be able to certify their serious health condition and sign the form before they can use it as documentation for their leave application.

If your patient’s family member is applying for family leave to care for your patient, you can fill out the Certification of Serious Health Condition form (or other acceptable documentation) for the family member IF they are a designated authorized representative. Fill out the Certification of Serious Health Condition form with information about your patient’s health condition, how long it will last and whether your patient will require care. Your patient’s family member will qualify for time off based on this information.

Yes. If a patient prefers, they can use a Family Medical Leave Act form or a doctor’s note instead, but it must include the same information as the Certification of Serious Health Condition form. To streamline this step, you can submit an electronic signature.

For patients whose medical condition could last longer than a year, enter a date one year in the future as the end date of their serious health condition. These patients will update their certification annually if their condition continues for longer than a year.