Connecticut workers taking CT Paid Leave to care for a relative need this five-page certification (CTPL-0009) from the relative's health care provider. Part A shows how the patient's condition qualifies as serious, and Part B states what care the patient needs and how much leave the caregiver requires. The form notes that claims are administered by Continental American Insurance Company.
The applicant completes their own details, the relationship, and the family member's and provider's information. The family member's health care provider completes Parts A and B and signs with credentials under penalties of perjury.
Download the current version from the source each time; forms change without notice.
Certification for Care of a Family Member with a Serious Health Condition
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
No. CT Paid Leave's document checklist says the family member's health care provider may not charge a fee for completing the Certification for Care of a Family Member with a Serious Health Condition, citing Connecticut General Statute 31-49r(e). The form must be returned within 15 days.
Part A, checking each way the patient's condition qualifies as serious (inpatient care, continuing treatment, pregnancy, chronic, long-term, multiple treatments or organ donation) with supporting facts. Part B, stating the care the patient needs and whether the caregiver's leave is continuous, reduced schedule or intermittent, with frequency and duration estimates for the next 6 months.
CT Paid Leave accepts MDs and DOs, podiatrists, dentists, clinical psychologists, optometrists, chiropractors, nurse practitioners, nurse-midwives, clinical social workers and physician assistants practicing within scope in Connecticut, Christian Science practitioners, and any provider whose certification the employer or group health plan accepts.