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Documents and Forms

Certification of Serious Health Condition form

Where can I find the Certification of Serious Medical Condition form?

Who should use the Certification of Serious Health Condition form?

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

How do I complete the form?

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.

Can someone else complete the form for my patient?

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.

Can patients use something other than the Certification of Serious Health Condition form?

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.

My patient is experiencing a chronic condition or extended treatment for which I can’t estimate an end date. How do I note that on the certification form?

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.