When MetLife administers an employee's leave under the FMLA, a similar state law or a company leave policy, it asks the employee's health care provider to certify the serious health condition on this five-page form rather than the DOL's WH-380-E. The provider records which FMLA category applies, the medical facts, job functions the patient can't perform, and whether leave is continuous, intermittent or a reduced schedule.
The employee completes Section 1 (name, claim number and employer) before handing the form over, and their name and claim number go on every page. The health care provider completes Section 2 (medical condition), Section 3 (leave dates) and Section 4 (provider information), and signs on the last page.
Completed by the employee, in capital letters, before the form goes to the provider: first, middle and last name, the MetLife claim number and the employer's name. The employee should also write their name and claim number in the spaces at the top of every later page.
Limit answers to the condition for which the employee is seeking leave. Give the date the condition began and a best estimate of how long it will last, either chronic or ongoing with no likely end, or an estimated end date. For FMLA purposes, incapacity means inability to work, attend school or perform regular daily activities because of the condition, its treatment or recovery.
Check each category that applies: (1) inpatient care, with admission and release dates; (2) incapacity plus treatment; (3) pregnancy, with the estimated or actual delivery date; (4) chronic conditions needing treatment visits at least twice a year; (5) permanent or long-term conditions under continuing supervision; (6) conditions requiring multiple treatments. If none applies, check (7) and go straight to Section 4 to sign.
Describe the relevant medical facts that support the need for leave: symptoms, diagnosis, doctor visits and medications prescribed. Then answer whether the patient is unable to perform one or more job functions and, if so, which. If the employer gave no job description, base this on the employee's own account of the essential functions. Absence for scheduled treatment counts as being unable to perform them.
Option 1 is continuous leave: time off for entire workdays over a consecutive period, such as April 1 to April 30. Check No if continuous leave is not medically necessary, or Yes and give the leave start date and an estimated end date. MetLife asks for an estimated end date, noting that it can be reviewed for possible extension later if needed.
Option 2 covers intermittent absences or a reduced schedule. Give the start and estimated end dates, then two estimates where they apply: office visits or treatments (up to how many times per week, month or year, and how long each takes) and unpredictable episodes of incapacity (how often, and how long each lasts in minutes, hours or workdays). If both options are used, their dates cannot overlap.
Enter the provider's full name, area of specialty, address, and office phone and fax numbers. Sign and date the form on this last page, attesting that you are the treating provider and that the clinical information relates to the absences listed. A fraud notice above the signature warns that submitting false or misleading information may be a crime.
Download the current version from the source each time; forms change without notice.
Group Disability Certification of health care provider for Employee's serious health condition
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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It serves the same purpose for leaves MetLife administers, whether under the FMLA, similar state laws or company leave. On MetLife's form the provider picks the category of serious health condition, describes the medical facts and affected job functions, and estimates continuous or intermittent leave, and the employee's MetLife claim number goes on every page.
MetLife's instructions say terms such as lifetime, unknown, as needed or indeterminate may not be sufficient to determine FMLA coverage, and the form may be returned as incomplete. For intermittent leave, Section 3 asks for an estimate instead: up to how many times per week, month or year, and up to how many minutes, hours or days each time.
Yes. Section 3 has Option 1 for continuous leave and Option 2 for intermittent or reduced schedule leave, and both can be completed, but the dates for each type cannot overlap. Each option needs a start date and an estimated end date, which MetLife says can be reviewed for a possible extension later.
Mail or fax the completed form to MetLife Disability using the address and fax number printed on page 5, or the employee can upload it to their claim through MetLife's MyBenefits website. Make sure the employee's name and claim number are on each page so every page is matched to the leave claim.