Prudential uses this 5-page form when it handles both an employee's group disability claim and the related medical leave, so one certification serves both decisions. The treating provider records the condition type, ICD diagnosis codes, treatment dates, loss of function, return-to-work plan and expected absence pattern. Prudential returns forms that lack sufficient medical facts or rely on open-ended answers as incomplete.
The employee completes Section 1 (name, claim number, Social Security number, birth date, employer and the required control number) and signs to let the provider clarify information. For disability purposes, the rest must be completed and signed by a doctor as defined in the employer's group contract.
The employee enters name, claim number, Social Security number, date of birth, gender, employer's name and the control number, which is marked required. By signing, the employee lets the provider clarify the clinical reason for time off and acknowledges that missing information by the due date may mean the leave is not approved. A note reminds the employee to have a doctor as defined in the group contract complete the certification.
Check injury, illness or pregnancy. For an injury, say whether it was a motor vehicle accident and in which state; for pregnancy, give the estimated or actual delivery date. Enter the date significant loss of function occurred, any overnight admission with hospital name and admit and discharge dates, and the first, last and next visit dates. If other treating providers or consultants are involved, page 2 asks for their name, specialty and phone.
List primary and secondary clinical diagnoses with ICD codes, any surgery date and procedure details, and whether the claimant is competent to endorse checks. Describe relevant medical facts such as diagnosis, pregnancy complications, symptoms or a continuing treatment regimen, then tests and procedures with dates, and current medications, treatment and prognosis. Page 3 adds the nature of the medical impairment (loss of function) and any non-medical factors affecting functional abilities.
Give the return-to-work date and mark full time, part time or work limitations. State whether you were given a job description or discussed the job's essential functions, which job functions the patient is or was unable to perform, and the return-to-work plan with any limitations. Prudential uses this to judge both disability and the leave period.
List only the dates and times the patient must be absent because of the condition. Check every absence pattern that applies: single continuous absence, short-term episodic absences, or chronic or lifelong absences, which require at least 2 office visits a year. For a single continuous absence, give start and end dates; if the end date is unknown, give the next office visit for reevaluation.
Mark whether intermittent absences are foreseeable (appointments, therapy), unforeseeable (flare-ups) or both. Give frequency as a number of times per week, month or year, checking only one, and length in minutes, hours or full days per episode. The printed example is 3 times per month for 2 hours. Include travel time and give start and end dates for the intermittent period.
If the employee needs a reduced work schedule, check the box and estimate it with start and end dates, hours per day and days per week. The form asks for this estimate 'if any', so the box stays unchecked when the patient does not need a reduced schedule between or after absences.
Enter your name, area of specialty, license or NPI number with the state or country of licensure, and office phone, fax and address. The form notes license details are not needed for federal FMLA but may be for state leave laws. On page 5, read the GINA disclaimer and fraud notice, then sign and date as treating provider, confirming you understand the certification must come from a doctor as defined in the group contract.
Download the current version from the source each time; forms change without notice.
Certification of Health Care Provider for Employee's Serious Health Condition for Disability and Medical Leave
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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For disability purposes, the certification must be completed by a doctor as defined in the employer's group contract, and all medical facts must come from the treating provider. The employee completes and signs the identification section on page 1. The treating provider signs under the GINA disclaimer and fraud notice on page 5.
The form warns that answers such as 'Lifetime,' 'Unknown' or 'As Needed' are not sufficient and will be returned as incomplete, as will a form without sufficient medical facts. If the end date is unknown, give the next office visit for reevaluation, and include travel time in intermittent estimates.
Section 3 asks for primary and secondary clinical diagnoses and prints 'ICD Code is Required' beside them. The same section says that not completing it will not affect the patient's rights to medical leave; the information is weighed for the disability benefit and for leave purposes.
GL.2010.195 is the combined disability and medical leave certification, with diagnosis codes, loss of function, non-medical factors and a return-to-work plan. GL.2019.198 certifies the employee's serious health condition for leave only and is also published in Spanish. Complete the version Prudential or the employee sent for the claim.