When Prudential administers an employee's FMLA or state family leave to care for a family member, it uses this certification in place of the WH-380-F. The family member's provider describes the condition, checks the qualifying category, lists the help the patient needs with daily activities, and estimates continuous or intermittent absence. Prudential decides the leave.
The employee completes Sections 1 and 2 (caregiver and family member information) and signs; the family member's health care provider completes Sections 3 to 5 and signs on page 6.
Download the current version from the source each time; forms change without notice.
Certification of Health Care Provider for Family Member'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.
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The form says certifications marked 'Lifetime', 'Unknown' or 'As Needed' will be returned. Frequency and duration of flare-ups must be numbers, and when an end date is not known the provider should list the next office visit for reevaluation.
Yes. Prudential lists a Spanish version of the Certification of Health Care Provider for Family Member's Serious Health Condition alongside the English form. Medical facts must still be given in English or with a translation.
Section 3 has a checklist that includes ambulation, bathing, cooking, eating, dressing, grooming, toileting, medication management, coordinating medical care, paying bills, shopping, transportation, wound care and psychological or emotional support, with space to explain other needs.