Prudential sends this 4-page certification when it administers an employee's FMLA or state leave for the employee's own serious health condition. The provider marks which serious health condition category applies, notes job restrictions, and estimates continuous, follow-up, reduced-schedule or intermittent absence. Prudential uses the answers to approve or deny the leave, and vague estimates are returned as insufficient.
The employee completes Section 1 (identification, employer and the required control number) and signs to let the provider clarify information. The health care provider completes Sections 2 to 4 and signs as treating health care provider on page 4.
The employee enters name, claim number, Social Security number, date of birth, phone numbers, employer's name and the control number, which is marked required. The employee's signature gives the provider permission to clarify information about the serious health condition and acknowledges that missing the due date may lead to the leave not being approved or other action by the employer.
All medical facts must come from the provider, in English or with a translation, with extra pages attached if needed. Limit answers to the condition behind the leave. Mark injury, illness or pregnancy, then give the approximate start date, expected duration, and first, last and next visit dates. If other providers are involved or the patient was referred, enter their name, specialty and office contact details.
Check every category that applies: pregnancy or prenatal care with delivery dates; inpatient care with admit and discharge dates; incapacity of more than 3 consecutive full days with 2 visits within 30 days or 1 visit plus a regimen of treatment; a chronic condition meeting all three bullets; a permanent or long-term condition under supervision; conditions requiring multiple treatments; or other, with a description.
Answer two yes-or-no questions: whether you were given a job description or discussed the employee's essential job functions, and whether the patient is unable to perform one or more of those functions. If the answer to the second is yes, identify the functions the employee cannot perform in the space provided on page 2.
List only the dates or times the patient cannot perform the essential job functions because of the condition, using medical history and your knowledge of it. For a Single Continuous Absence Period, give start and end dates. If the end date is unknown, give the next office visit for reevaluation rather than leaving it blank.
State whether the employee needs follow-up appointments or a part-time or reduced schedule, and whether that is medically necessary. Estimate the treatment schedule, including dates of scheduled appointments and time needed for each, recovery included. For a reduced schedule, give start and end dates, hours per day and days per week.
Give start and end dates for the intermittent period. If the condition causes episodic flare-ups, estimate their frequency and duration over the next 6 months as numbers: times per week, month or year (check only one), and hours or full days per episode. Include travel time. The form's example is 1 episode per month lasting 1 to 2 full days.
Enter your name, area of specialty, license or NPI number with the state or country of licensure, and office phone, fax and address. Read the GINA disclaimer, which asks you not to provide genetic information, and the fraud notice, then sign and date as treating health care provider, certifying that all statements on the form are true.
Download the current version from the source each time; forms change without notice.
Certification of Health Care Provider for Employee's Serious Health Condition
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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Yes. Prudential publishes a Spanish edition, GL.2019.198 SP, Edition 09/2024. The English form's instructions say the provider's documentation must be in English or be accompanied by a translation of the medical facts, so check what Prudential needs before writing clinical answers in Spanish.
Terms such as 'Lifetime,' 'Unknown' or 'As Needed' will be returned as insufficient. Prudential wants your best estimate based on medical knowledge, experience and examination. If the end date is unknown, list the next office visit for reevaluation, and give flare-up frequency and duration as numbers that include travel time.
Section 4 asks for a license or NPI number and the state or country where you are licensed, but the form notes this is not required to certify leave under the federal FMLA. It may be required to certify leave under specific state leave laws. The same section collects your name, specialty and office contact details.
It does the same job, certifying the employee's own serious health condition for leave, but in Prudential's layout with a claim number and control number. Use it when Prudential administers the leave. For a combined disability and leave claim, Prudential uses the longer GL.2010.195 instead.