New York Life Group Benefit Solutions sends this 3-page certification when its Leave Solutions unit administers FMLA or state leave for an employee's own serious health condition. The employee fills in Section I and hands it to the treating provider, who estimates onset, duration, incapacity and leave frequency in Section II. The leave team uses those answers to approve or deny protected time off.
The employee completes Section I (job title and regular work schedule) and signs it. The health care provider completes Section II: Subsection A for every leave, plus Subsection B, C or D for continuous, reduced-schedule or intermittent leave, and signs on page 3.
The header already shows the date prepared, employee and employer names, notification number, reason for leave, the leave period requested and the 'Must Be Returned By' date. The employee adds job title and regular work schedule, signs and dates, then gives the form to the provider. Reading the requested leave period before you start keeps your estimates tied to the dates the employee actually asked for.
Enter your name, contact details and type of practice or specialty. Then give the approximate date the condition began, its probable duration, treatment dates in the past 12 months, any overnight admission dates, whether treatment visits will occur at least twice a year, whether prescription medication was prescribed, pregnancy with expected delivery date, and whether flare-ups will periodically prevent work. List job functions the employee cannot perform based on the employee's own job description, and describe other relevant medical facts, omitting diagnosis for California or Connecticut leave.
Answer whether the employee will be incapacitated for a single continuous period because of the condition, including time for treatment and recovery. If yes, give an estimated start date and end date for the period of incapacity. The form states it is considered incomplete or insufficient if these dates are missing when continuous leave is requested.
State whether it is medically necessary for the employee to work part-time or on a reduced schedule, which includes time for follow-up treatment appointments. If yes, estimate the schedule in hours per day and times per week or month, with a start and end date. A reduced-schedule request without these estimates is treated as incomplete.
Confirm whether intermittent time off is needed and give the start and end dates of that period. Under Office Visits/Treatments, estimate the maximum frequency of follow-up visits over the next 6 months, with hours per visit and times per week or month. Under Incapacity, estimate the maximum frequency of episodes over the next 6 months, with hours per day or days per episode. Both estimates are required for intermittent leave.
Page 3 ends with an Additional Information box for anything that did not fit above, followed by the provider's signature and date. The instructions remind providers to sign on the last page, and the form asks that all pages be returned. The Paperwork Reduction Act notice at the bottom says not to send the completed form to the Wage and Hour Division.
Download the current version from the source each time; forms change without notice.
Certification of Health Care Provider for Employee's Own Illness
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 is the due date NYL GBS Leave Solutions set for the completed certification. The form explains that the employer must give the employee at least 15 calendar days to return it, and that failing to provide a complete and sufficient certification may result in denial of the FMLA request. Return all three pages before that date.
Avoid it. The provider instructions say terms such as 'lifetime,' 'unknown' or 'indeterminate' may not be sufficient to determine FMLA coverage. Give your best estimate based on your medical knowledge, experience and examination of the patient, such as start and end dates or a number of episodes per week or month.
Subsection A is required for every type of leave. Then complete the subsection that matches the leave requested: B for one continuous period, C for a reduced or part-time schedule, D for intermittent time off. The form states it is considered incomplete or insufficient if the matching estimates are missing for that leave type.
It serves the same purpose as the WH-380-E and reprints the Labor Department's paperwork burden statement, but it is NYL GBS's own layout, with Subsections A to D and header boxes for the notification and absence numbers. It is the version to use when NYL GBS Leave Solutions administers the employee's leave.