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MetLife DIS-HCPC-FMLA-FMHC: Family Member Certification

When an employee asks for leave to care for a family member with a serious health condition, MetLife uses this form to evaluate the request under the FMLA, similar state leave laws or company leaves it administers for the employer. The family member's provider describes the condition, the care needed, which of six serious health condition categories applies, and the continuous or intermittent leave the employee needs.

Who completes it

The family member's treating provider completes Section 3 (medical condition), Section 4 (leave dates) and Section 5 (provider information and signature). The employee completes Sections 1 and 2, including the patient's relationship to the employee.

Submitting and payment

How to submit it
Return it to MetLife Disability by mail or fax, or the employee uploads it through MetLife's MyBenefits site. The employee's name and claim number go on every page.

Good to know

  • Six categories are offered: inpatient care, incapacity over three full days with treatment, pregnancy, chronic conditions needing visits at least twice a year, permanent or long-term conditions, and multiple treatments.
  • If the patient is an adult child, list the ADLs or IADLs they need help with; the child must be incapable of self-care, with limits in three or more.
  • California physicians may not disclose the patient's diagnosis without the patient's consent, and the form defines an overnight stay separately for California employees.
  • Continuous and intermittent leave dates cannot overlap. Give an estimated end date, which can be extended later, and frequency and duration for visits and flare-ups.

Get the official form

Download the current version from the source each time; forms change without notice.

Group Disability Certification of health care provider for family member serious health condition

Official pagePDF

How this list is checked

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.

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Frequently asked questions

What if none of the serious health condition categories apply?

Check option 7, None of the above, and go directly to Section 5 to sign and date the form. Options 1 to 6 are the serious health condition categories, from inpatient care to multiple treatments, that the request is weighed against.

Can the provider write as needed for the leave duration?

It is risky. The 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. Give a best estimate of the condition's duration, an estimated end date for leave, and expected frequency and length of absences.

Is this MetLife form the same as the WH-380-F?

It covers the same situation as the Department of Labor's WH-380-F, certification of a family member's serious health condition, but in MetLife's format. MetLife also uses it for similar state leave laws and company leaves it administers, and requires the claim number on every page.