Sun Life uses GSTDFM-9857 when an employee covered by a Sun Life private or equivalent state paid family and medical leave plan needs leave to care for a family member with a serious health condition. The family member's provider confirms the condition category, the medically necessary care and whether leave is continuous, intermittent or a reduced schedule.
The employee completes Sections 1 and 2 and gives all pages to the family member's provider; that health care provider completes Section 3, Parts A and B, with license and NPI numbers, and signs Section 5.
Download the current version from the source each time; forms change without notice.
Paid Family and Medical Leave (PFML) – Care for family member
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The employee instructions say the completed form must reach Sun Life no later than 15 days from the date the leave was requested. Missing information can delay processing, so the provider section should be complete when it goes back.
Possibly. The instructions note that the family member may be required to complete an authorization form so the provider can release health information to the employee. The employee is asked to give the provider all pages of the form, including their completed Sections 1 and 2.
The provider gives start and end dates for the intermittent period and estimates how often episodes occur and how long each lasts, per day, week, month or year. A separate question covers a reduced work schedule in hours per day and days per week.