An employee covered by a private paid family and medical leave plan insured by The Standard who needs leave to care for a family member receives a Care of Family Member packet, and Form PFML-4 is its provider certification. The family member's provider documents the medical facts and the amount of care needed, and The Standard decides the claim.
The employee fills in the employee and family member information at the top; the family member's health care provider completes Part A (medical facts) and Part B (amount of care needed) and signs. The employer completes Part B of the separate PFML-1.
Download the current version from the source each time; forms change without notice.
Certification For Care Of Family Member With Serious Health Condition (Form PFML-4)
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It depends on where the employee works. The form says not to include the diagnosis or primary ICD code for patients working in Connecticut, Delaware, Massachusetts, Minnesota or Washington. In other states, the diagnosis field and optional ICD code can be completed.
The family member's health care provider. The family member, or an authorized representative, completes PFML-3 and gives it to their provider with the PFML-4. The provider retains it, and the employee keeps a copy for their records.
Yes. Part A asks whether the family member is an active service member and, if so, whether the condition results from military service. It also asks about pregnancy, delivery dates and complications when the family member's condition is pregnancy.