Sun Life sells an insured Family Leave Insurance product that provides paid family leave where no state program applies, and this statement supports a caregiving claim under it. An employee caring for a family member with a serious health condition brings it to that family member's provider, who confirms the condition category, the care needed and the leave schedule.
The employee completes Sections 1 and 2 (employee and family member information, care to be given); the family member's health care provider completes Sections 3 to 5 and signs Section 6.
Download the current version from the source each time; forms change without notice.
Family Leave Insurance (FLI) Care for Family Member Claim Statement
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It is an insured product Sun Life offers to employers to provide paid family leave where no state paid leave program applies. Claims for care of a family member under it use GSTDFM-11179, which the family member's health care provider completes.
The provider selects a serious health condition category, such as inpatient care, incapacity plus treatment, pregnancy, chronic, permanent or long-term, or multiple treatments, and gives the onset date and expected duration. The form notes that some state or local laws may not allow disclosure of the diagnosis or course of treatment.
The provider section asks for license number and state, and lists the NPI number as needed when the provider practices outside Colorado. Phone, fax, email and type of practice or specialty are requested as well.