New York Life Group Benefit Solutions uses form 123769 when its Leave Solutions unit administers an employee's request for FMLA or state leave to care for a family member. It is NYL GBS's version of the WH-380-F. The family member's provider answers questions on the condition and the care needed for continuous, reduced-schedule or intermittent leave, by the return date printed at the top.
The employee completes Section I with the family member's name, relationship and care to be given; the family member's health care provider completes Section II, Subsections A to D as they apply, and signs.
Download the current version from the source each time; forms change without notice.
Certification of Health Care Provider for Care of a Family Member
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The employer must give at least 15 calendar days, and the return date is printed in the header as 'Must Be Returned By'. If NYL GBS finds the certification incomplete or insufficient, the employee gets at least 7 more calendar days to fix it.
No. Under GINA, and CalGINA where it applies, providers are asked not to give genetic information unless leaving it out would make the certification incomplete. For leave under the District of Columbia Family and Medical Leave Act, genetic information should never be provided.
Subsection D asks for the dates the patient needs care and two separate estimates over the next 6 months: the maximum frequency and duration of office visits or treatments, and the maximum frequency and duration of episodes of incapacity. It also asks what care the patient needs during that time.