Principal Life uses the GP62712 packet for state paid family and medical leave claims under its private or equivalent plans when the reason is a serious health condition, the employee's own or a family member's. Pages 6 and 7 are the Health Care Provider Medical Certification: ICD-10 codes, onset, condition category, leave frequency and visit history. Principal decides the claim from the full packet.
The employee completes the Employee Statement (page 2) and the employer the Employer Statement (pages 3 to 5); each treating health care provider completes and signs the Medical Certification on pages 6 and 7.
Download the current version from the source each time; forms change without notice.
Paid Family and Medical Leave Serious Health Condition Health Care Provider Medical Certification
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The provider checks one or more categories: inpatient care (including a neonatal intensive care unit), a permanent or long-term condition under supervision, multiple treatments, a chronic condition with at least two visits a year, pregnancy or prenatal care, or incapacity with treatment.
Yes. The footer of GP62712 cites the Spanish edition SP1963, which Principal posts alongside the English packet. The provider pages ask the same questions in both editions, including ICD-10 codes, onset date and visit frequency.
Yes. Principal's instructions say claims can be submitted on the web through its claim filing site, and employers can complete their statement there too. Paper packets can also be mailed, faxed or emailed to Principal's Group Life and Disability Claims unit.