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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

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What is certification-of-health-care-provider-for-family-members?

The certification-of-health-care-provider-for-family-members is a document that validates the medical necessity of taking time off from work to care for a family member who has a serious health condition.

Who is required to file certification-of-health-care-provider-for-family-members?

Employees who are requesting family leave under the Family and Medical Leave Act (FMLA) to care for a family member must file this certification.

How to fill out certification-of-health-care-provider-for-family-members?

To fill out the certification, the health care provider must provide information including the patient's medical condition, the need for leave, and the duration of the leave required.

What is the purpose of certification-of-health-care-provider-for-family-members?

The purpose of the certification is to provide employers with documentation to support the employee's request for leave to care for a family member, ensuring the leave is warranted under FMLA.

What information must be reported on certification-of-health-care-provider-for-family-members?

The certification must include the patient's health condition, the expected duration of the condition, the dates when the employee is needed to provide care, and any other relevant medical information.

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