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Certification of Health Care Provider for
Employees 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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How to fill out certification of health care

How to fill out certification of health care
01
To fill out a certification of health care, follow these steps:
02
Obtain the certification form from the appropriate health care organization or agency.
03
Read the instructions and requirements carefully.
04
Provide personal information such as your full name, date of birth, and contact details.
05
Indicate the purpose of the certification, whether it is for employment, school, or other reasons.
06
Answer the questions about your medical history honestly and thoroughly.
07
If necessary, provide additional documents or medical records to support your certification.
08
Pay any applicable fees for processing the certification.
09
Review the filled-out form for any errors or missing information.
10
Sign and date the certification form.
11
Submit the completed form to the designated health care organization or agency.
Who needs certification of health care?
01
Certification of health care may be needed by:
02
- Individuals applying for certain jobs in the health care industry, such as nurses, doctors, or medical technicians.
03
- Students applying for health-related programs or courses.
04
- Individuals traveling to certain countries that require proof of vaccinations or medical clearance.
05
- Individuals participating in sports or physical activities that require a medical certification.
06
- Individuals seeking insurance coverage for specific medical conditions or treatments.
07
- Individuals applying for disability benefits or assistance programs that require proof of medical conditions.
08
- Individuals participating in clinical trials or medical research studies.
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What is certification of health care?
Certification of health care is a document or form that verifies the physical or mental health status of an individual.
Who is required to file certification of health care?
Individuals who are applying for certain benefits or services may be required to file certification of health care.
How to fill out certification of health care?
Certification of health care can be filled out by providing accurate and truthful information about the individual's health status.
What is the purpose of certification of health care?
The purpose of certification of health care is to ensure that individuals meet the health requirements for certain benefits or services.
What information must be reported on certification of health care?
Information such as the individual's medical history, current health status, and any treatments or medications being taken must be reported on certification of health care.
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