Connecticut workers claiming CT Paid Leave for their own illness, injury or pregnancy need their health care provider to complete this four-page certification (CTPL-0004). Part A asks the provider to check each way the condition qualifies as serious, from inpatient care to chronic conditions and organ donation, with supporting facts. Part B gives the leave pattern and dates.
The applicant fills in their personal information; the health care provider completes the provider block (specialty, license number and state), 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 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.
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Incapacity of more than three consecutive full calendar days plus either two or more in-person or telemedicine visits within 30 days, the first within 7 days, or one visit within 7 days that results in a regimen of continuing treatment, such as prescription medication. Give the incapacity dates and visit dates.
For CT Paid Leave, incapacity means the inability to work, attend school or perform regular daily activities because of the condition, its treatment or recovery from it. Part A uses that definition for inpatient care, continuing treatment and pregnancy, and Part B turns it into continuous, reduced-schedule or intermittent leave dates.
MDs and DOs, podiatrists, dentists, clinical psychologists, optometrists, chiropractors, nurse practitioners, nurse-midwives, clinical social workers and physician assistants practicing within scope in Connecticut, plus Christian Science practitioners and any provider the employer or group health plan accepts. All must sign the form.