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Certification of Health Care Provider for Family Members Serious Health Condition (Family and Medical Leave Act)U.S. Department of Labor Wage and Hour Division DO NOT SEND COMPLETED FORM TO THE DEPARTMENT
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What is certification of health provider?
Certification of health provider is a document completed by a healthcare professional that verifies the medical condition of an individual.
Who is required to file certification of health provider?
The individual seeking a benefit, such as an employee requesting leave under the Family and Medical Leave Act, is required to file certification of health provider.
How to fill out certification of health provider?
To fill out certification of health provider, the healthcare provider must provide information about the patient's medical condition, treatment plan, and estimated duration of the condition.
What is the purpose of certification of health provider?
The purpose of certification of health provider is to verify the medical condition of an individual and support their request for a benefit or accommodation.
What information must be reported on certification of health provider?
The certification of health provider must include the patient's diagnosis, treatment plan, and estimated duration of the medical condition.
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