Washington Paid Family and Medical Leave uses this one-page form to confirm a birth. The birthing parent relies on it for the first six weeks of medical leave to recover, and either parent uses it for family leave to bond with the baby. The provider, midwife or facility representative records only the child's date and place of birth and signs.
The parents complete Section 1 with their names, dates of birth and Paid Leave Customer IDs; a health care provider, midwife or healthcare facility representative completes and signs Section 2.
Download the current version from the source each time; forms change without notice.
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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A health care provider as defined in RCW 50A.05.010, a midwife, or a representative of a healthcare facility. The signer declares under penalty of perjury that the information is true and gives their name, title, type of practice, phone and business address.
Yes. Section 1 has fields for the parent who gave birth and the non-birthing parent if they are taking leave. Both parents can use the certification for family leave to bond, though each type of leave requires its own application.
Yes. ESD publishes it as a bilingual English and Spanish form, the Certificado de nacimiento, on page 4 of its Pregnancy and Birth Certifications packet, updated June 2024. The PDF has no fillable fields.