Paid family leave and state disability certifications for providers

Solicitud de beneficios del Seguro por Incapacidad (DI)

Certifies that the claimant is unable to do regular or customary work because of illness, injury, pregnancy or surgery, with diagnosis, ICD codes and expected return-to-work date, to establish a California State Disability Insurance (DI) claim.

Completed by

Licensed physician/practitioner (MD/DO, chiropractor, podiatrist, optometrist, dentist, psychologist, NP, PA; licensed midwife/nurse-midwife for normal pregnancy/childbirth)

Issued by

California Employment Development Department (EDD), State Disability Insurance

Format

Online only

Language

English and Spanish

Certifies that the care recipient has a serious health condition and requires care by the claimant (with diagnosis, ICD codes, estimated duration and hours per day of care) for a California Paid Family Leave care claim.

Completed by

Care recipient's licensed physician/practitioner

Issued by

California Employment Development Department (EDD), State Disability Insurance

Format

Online only

Language

English

Extends an existing California DI claim by updating treatment status, diagnosis/ICD codes, next appointment and the new estimated return-to-work date.

Completed by

Treating licensed physician/practitioner

Issued by

California Employment Development Department (EDD), State Disability Insurance

Format

Sent for each case

Language

English

Certifies that the care recipient still needs care so a California Paid Family Leave care claim can continue beyond the originally certified period.

Completed by

Care recipient's licensed physician/practitioner

Issued by

California Employment Development Department (EDD), State Disability Insurance

Format

Sent for each case

Language

English

Certifies the non-work-related disability of a California state employee covered by Nonindustrial Disability Insurance (NDI) instead of SDI.

Completed by

Treating licensed physician/practitioner

Issued by

California Employment Development Department (EDD), State Disability Insurance

Format

Fillable PDF

Language

English

Certifies the care recipient's serious health condition and need for care for a California state employee's NDI Family Care Leave claim.

Completed by

Care recipient's licensed physician/practitioner

Issued by

California Employment Development Department (EDD), State Disability Insurance

Format

Fillable PDF

Language

English

Certifies the claimant's or family member's serious health condition and the leave duration and absence parameter (7-day or 30-day limit) for Colorado FAMLI medical or care leave.

Completed by

U.S.-licensed health care provider (any person licensed, certified or registered under federal or Colorado law to provide medical or emergency services)

Issued by

Colorado Department of Labor and Employment, Division of Family and Medical Leave Insurance (FAMLI)

Format

Online portal or EMR

Language

English

Health care provider certification for an employer's Unum-insured private plan under Colorado Family and Medical Leave Insurance (FAMLI).

Completed by

Health care provider of the employee or family member

Issued by

Unum Group (Unum Life Insurance Company of America)

Format

Fillable PDF

Language

English

Documents a newborn's admission to a neonatal unit or higher level of care so a parent can take Colorado FAMLI Neonatal Care Leave (from January 1, 2026).

Completed by

Admitting hospital/neonatal care team (not specified on the page)

Issued by

Colorado Department of Labor and Employment, Division of Family and Medical Leave Insurance (FAMLI)

Format

Online portal or EMR

Language

English

Health care provider certifies the employee's own serious health condition (including pregnancy) for Colorado FAMLI benefits under a Guardian private plan.

Completed by

Employee's health care provider

Issued by

The Guardian Life Insurance Company of America (Guardian)

Format

Fillable PDF

Language

English

Certifies the employee's own serious health condition (inpatient care, continuing treatment, pregnancy, chronic or long-term condition) with incapacity dates for CT Paid Leave income replacement.

Completed by

Employee's health care provider (MD/DO, podiatrist, dentist, clinical psychologist, optometrist, chiropractor, NP, nurse-midwife, clinical social worker, PA)

Issued by

Connecticut Paid Leave Authority (claims administered by Aflac)

Format

Sent for each case

Language

English and Spanish

Certifies a family member's serious health condition and the employee's need to provide care, with dates, for CT Paid Leave caregiver benefits.

Completed by

Family member's health care provider

Issued by

Connecticut Paid Leave Authority (claims administered by Aflac)

Format

Sent for each case

Language

English and Spanish

Certifies a current service member's serious injury or illness so a family member can take CT Paid Leave military caregiver leave.

Completed by

Service member's health care provider (DoD, VA, TRICARE or other provider)

Issued by

Connecticut Paid Leave Authority (claims administered by Aflac)

Format

Sent for each case

Language

English and Spanish

Health care provider confirms whether the illness or injury meets the FMLA definition of a serious health condition, how many weeks of leave are needed, and whether reduced-schedule or intermittent leave applies, for Delaware Paid Leave medical or family caregiver leave.

Completed by

Claimant's or care recipient's health care provider (or delegated staff)

Issued by

Delaware Department of Labor, Division of Paid Leave

Format

Online only

Language

English

Health care provider certification for an employer's Unum-insured private plan under Delaware Paid Family and Medical Leave.

Completed by

Health care provider of the employee or family member

Issued by

Unum Group (Unum Life Insurance Company of America)

Format

Fillable PDF

Language

English

Formulario de certificación médica que justifica la licencia familiar

Documents a family member's serious health condition and the care the claimant will provide for DC Paid Family Leave family leave.

Completed by

Family member's licensed health care provider

Issued by

District of Columbia Department of Employment Services, Office of Paid Family Leave

Format

PDF

Language

English and Spanish

Formulario de certificación médica que justifica la licencia médica

Documents the claimant's serious health condition (pregnancy, inpatient care, chronic condition, continuing treatment) and the continuous/intermittent leave needed for DC Paid Family Leave medical leave.

Completed by

Claimant's licensed health care provider

Issued by

District of Columbia Department of Employment Services, Office of Paid Family Leave

Format

PDF

Language

English and Spanish

Formulario de certificación médica que justifica la licencia prenatal

Certifies pregnancy-related prenatal care or incapacity for DC Paid Family Leave prenatal leave.

Completed by

Pregnant claimant's licensed health care provider (OB/GYN, midwife, family physician, NP)

Issued by

District of Columbia Department of Employment Services, Office of Paid Family Leave

Format

PDF

Language

English and Spanish

Employee's claim for Hawaii Temporary Disability Insurance benefits for a non-work-related illness or injury, with the attending practitioner's certification of disability.

Completed by

Attending physician/practitioner

Issued by

Hawaii Department of Labor and Industrial Relations, Disability Compensation Division

Format

Sent for each case

Language

English

Certifies the employee's own serious health condition (incl. pregnancy/post-birth recovery) that prevents them from working and its probable duration, for Massachusetts paid medical leave.

Completed by

Employee's health care provider (MD/DO, dentist, podiatrist, chiropractor, clinical psychologist, optometrist, NP, nurse-midwife, clinical social worker, PA, Christian Science practitioner)

Issued by

Massachusetts Department of Family and Medical Leave (DFML)

Format

Fillable PDF

Language

English

Health care provider certification of a serious health condition (own or family member) for an employer's Unum-insured private plan under Massachusetts Paid Family and Medical Leave.

Completed by

Health care provider of the employee or family member

Issued by

Unum Group (Unum Life Insurance Company of America)

Format

Fillable PDF

Language

English

Certifies that the employee's family member has a serious health condition requiring the employee's care, with the type, frequency and duration of care, for Massachusetts paid family leave.

Completed by

Family member's health care provider (MD/DO, dentist, podiatrist, chiropractor, clinical psychologist, optometrist, NP, nurse-midwife, clinical social worker, PA, Christian Science practitioner)

Issued by

Massachusetts Department of Family and Medical Leave (DFML)

Format

Fillable PDF

Language

English

Health care provider documentation of a child's birth and parent's relationship for bonding leave under a Unum-insured Massachusetts PFML private plan.

Completed by

Health care provider (birth provider)

Issued by

Unum Group (Unum Life Insurance Company of America)

Format

Fillable PDF

Language

English

Care recipient's health care provider certifies the serious health condition for a Massachusetts family leave claim under a Guardian private plan.

Completed by

Care recipient's health care provider

Issued by

The Guardian Life Insurance Company of America (Guardian)

Format

Fillable PDF

Language

English

Claim for Massachusetts paid medical leave under a Guardian private plan; the doctor certifies the period of care and incapacity.

Completed by

Treating physician

Issued by

The Guardian Life Insurance Company of America (Guardian)

Format

Fillable PDF

Language

English

Certifies the applicant's own serious health condition, start date and length, leave schedule (continuous/intermittent with episode frequency) and affected job functions for Minnesota Paid Leave medical leave.

Completed by

Applicant's health care provider

Issued by

Minnesota Department of Employment and Economic Development, Minnesota Paid Leave

Format

Fillable PDF

Language

English

Certifies a family member's serious health condition and the care and schedule the applicant needs for Minnesota Paid Leave caring (family) leave.

Completed by

Family member's health care provider

Issued by

Minnesota Department of Employment and Economic Development, Minnesota Paid Leave

Format

Fillable PDF

Language

English

Certifies pregnancy-related incapacity, prenatal care or recovery from childbirth for Minnesota Paid Leave medical leave.

Completed by

Obstetric or other prenatal/postpartum health care provider

Issued by

Minnesota Department of Employment and Economic Development, Minnesota Paid Leave

Format

Fillable PDF

Language

English

Health care provider certification for an employer's Unum-insured private plan under Minnesota Paid Family and Medical Leave.

Completed by

Health care provider of the employee or family member

Issued by

Unum Group (Unum Life Insurance Company of America)

Format

Fillable PDF

Language

English

Certifies that the applicant or a family member needs safety leave related to domestic abuse, sexual assault or stalking under Minnesota Paid Leave.

Completed by

Health care or social service provider, advocate or other authorized certifier

Issued by

Minnesota Department of Employment and Economic Development, Minnesota Paid Leave

Format

Fillable PDF

Language

English

Optional provider confirmation that a child was born, the date of birth and the parents, for Minnesota Paid Leave bonding leave when no birth certificate or discharge record is available.

Completed by

Health care provider who attended the birth or treats the parent/child

Issued by

Minnesota Department of Employment and Economic Development, Minnesota Paid Leave

Format

Fillable PDF

Language

English

Certifies the employee's own or a family member's serious health condition (diagnosis/ICD-10, treatment dates, expected duration, hospitalization, intermittent schedule) for a voluntary NH PFML insurance claim.

Completed by

Patient's healthcare provider

Issued by

Metropolitan Life Insurance Company (MetLife) for the State of New Hampshire Paid Family and Medical Leave Plan

Format

Fillable PDF

Language

English

Certifies the patient's disability period, diagnosis/ICD code, estimated recovery date and pregnancy details for a New Jersey Temporary Disability Insurance (TDI) claim.

Completed by

Patient's licensed healthcare provider

Issued by

New Jersey Department of Labor and Workforce Development, Division of Temporary Disability and Family Leave Insurance

Format

Fillable PDF

Language

English

Certifies the family member's diagnosis/ICD code, need for full- or part-time care, first date care was needed and expected end of care for New Jersey Family Leave Insurance (FLI).

Completed by

Care recipient's licensed healthcare provider

Issued by

New Jersey Department of Labor and Workforce Development, Division of Temporary Disability and Family Leave Insurance

Format

Fillable PDF

Language

English

Lets the treating provider certify a longer period of disability for a claimant already approved for New Jersey TDI.

Completed by

Treating healthcare provider

Issued by

New Jersey Department of Labor and Workforce Development, Division of Temporary Disability and Family Leave Insurance

Format

Online only

Language

English

Notificación y prueba de reclamo por beneficios por discapacidad

Documents diagnosis, symptoms, objective findings, hospitalization and the period the claimant is unable to work for New York statutory short-term disability benefits (DBL).

Completed by

Health care provider (physician, chiropractor, dentist, podiatrist, psychologist, nurse-midwife, NP, PA)

Issued by

New York State Workers' Compensation Board

Format

Fillable PDF

Language

English and Spanish

Certificado de Proveedor de Atención Médica para el Cuidado de un Miembro de la Familia con un Problema de Salud Grave

Certifies that the employee's family member has a serious health condition and needs the employee's care, with the expected duration and frequency, for New York Paid Family Leave.

Completed by

Care recipient's health care provider (physician, PA, NP, RN, psychologist, LCSW, mental health practitioner, chiropractor, dentist, podiatrist, optometrist, PT, OT, SLP, audiologist, midwife) within scope of practice

Issued by

New York State Workers' Compensation Board (Paid Family Leave)

Format

Fillable PDF

Language

English and Spanish

Formulario de verificación de condición médica grave

Verifies the claimant's own or a family member's serious health condition, its start date, and the expected length (and frequency, if intermittent) of leave for Paid Leave Oregon medical or family leave.

Completed by

Patient's authorized health care provider per OAR 471-070-1000 (physician, physician associate, NP, nurse-midwife NP, direct-entry midwife, RN, psychologist, regulated social worker, optometrist, dentist, naturopathic physician, chiropractic physician within limits; also spiritual-means practitioners)

Issued by

Oregon Employment Department, Paid Leave Oregon

Format

Fillable PDF

Language

English and Spanish

Certifies the qualifying health condition category (hospital care, incapacity plus treatment, pregnancy/prenatal care, chronic, long-term, multiple treatments, sick child), medical facts, duration and full-time/intermittent leave needed for combined OFLA and federal FMLA leave.

Completed by

Employee's or family member's health care provider

Issued by

Oregon Bureau of Labor and Industries (BOLI)

Format

Word document

Language

English

Certifies OFLA-only leave for pregnancy/prenatal care (incl. fertility treatment) or sick child leave, with the medical facts, duration and leave schedule.

Completed by

Employee's or child's health care provider

Issued by

Oregon Bureau of Labor and Industries (BOLI)

Format

Word document

Language

English

Health care provider certification of a serious health condition for an employer's Unum-insured equivalent plan under Paid Leave Oregon.

Completed by

Health care provider of the employee or family member

Issued by

Unum Group (Unum Life Insurance Company of America)

Format

Fillable PDF

Language

English and Spanish

Formulario de verificación de nacimiento

Certifies the birth or expected birth of the claimant's child for Paid Leave Oregon bonding leave and the extra two weeks of family leave for the birthing parent.

Completed by

Health care provider authorized to certify the birth (obstetric provider, midwife, pediatric provider)

Issued by

Oregon Employment Department, Paid Leave Oregon

Format

PDF

Language

English and Spanish

Certifies an Oregon state employee's or covered family member's health condition category, medical facts, duration and full-time/intermittent/reduced-schedule leave for OFLA/FMLA.

Completed by

Physician or other health care provider of the employee or family member

Issued by

Oregon Department of Administrative Services, Chief Human Resources Office (state employees)

Format

Word document

Language

English

Verifies that the claimant or their child/dependent is a survivor of sexual assault, domestic violence, harassment, bias crimes or stalking for Paid Leave Oregon safe leave.

Completed by

Health care provider or licensed mental health professional/counselor (also law enforcement, attorney, clergy, Title IX coordinator, victim services provider)

Issued by

Oregon Employment Department, Paid Leave Oregon

Format

PDF

Language

English

Solicitud de Beneficios por Incapacidad, Ley Núm. 139 del 26 de junio de 1968, enmendada (Fase Industrial y Agrícola) - Parte C Certificado Médico o Psicológico

Certifies a worker's temporary non-occupational disability (diagnosis, treatment and period of incapacity) for Puerto Rico SINOT benefits under the government-administered plan.

Completed by

Each treating physician, chiropractor or psychologist authorized to practice in Puerto Rico (or the medical-records custodian of the treating institution)

Issued by

Puerto Rico Department of Labor and Human Resources (DTRH), Bureau of Workers' Benefits, Disability Insurance Program (SINOT)

Format

PDF

Language

English and Spanish

Certificado de nacimiento

Confirms a birth so the birthing parent can take the first six weeks of medical leave to recover and either parent can take family leave to bond.

Completed by

Health care provider who attended or treated the birthing parent

Issued by

Washington State Employment Security Department, Paid Family & Medical Leave

Format

PDF

Language

Bilingual

Certificado médico

Certifies the employee's own serious health condition, its start date and expected duration/frequency of incapacity for Washington paid medical leave.

Completed by

Employee's health care provider (MD/DO, NP, PA, midwife, clinical social worker, clinical psychologist, optometrist, PT, podiatrist, dentist, naturopath, chiropractor in limited cases)

Issued by

Washington State Employment Security Department, Paid Family & Medical Leave

Format

PDF

Language

Bilingual

Certificado de permiso familiar

Certifies that the employee's family member has a serious health condition and needs care, with expected duration, for Washington paid family leave.

Completed by

Family member's health care provider

Issued by

Washington State Employment Security Department, Paid Family & Medical Leave

Format

PDF

Language

Bilingual

Certificado médico de cuidado prenatal

Certifies the need for medical leave for prenatal care or pregnancy-related incapacity under Washington paid medical leave.

Completed by

Prenatal care provider (OB/GYN, family physician, midwife, NP)

Issued by

Washington State Employment Security Department, Paid Family & Medical Leave

Format

PDF

Language

Bilingual

Lets a health care provider designate an authorized representative for a patient who cannot complete Paid Family & Medical Leave administrative requirements or designate one themselves, attesting it is in the patient's best interest.

Completed by

Patient's health care provider

Issued by

Washington State Employment Security Department, Paid Family & Medical Leave

Format

Sent for each case

Language

English

Certificado médico por complicaciones en el parto

Certifies a need for more than six weeks of medical leave to recover from giving birth, or leave for birth complications.

Completed by

Treating obstetric or other health care provider

Issued by

Washington State Employment Security Department, Paid Family & Medical Leave

Format

PDF

Language

Bilingual