When a Delaware employer provides Paid Family and Medical Leave through a private plan insured by Unum, leave claims go to Unum, and this eight-page packet carries the provider's certification of the serious health condition. Pages 6 and 7 ask for the condition's start and duration, the treatment plan, work restrictions or the family member's care needs, and an estimate of continuous, intermittent or reduced-schedule leave.
The employee completes pages 1 to 3 and the top of page 6, and the employer completes pages 4 and 5. The health care provider of the employee or family member answers questions 1 to 8 on pages 6 and 7 and signs with printed name and specialty.
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Delaware Paid Family & Medical Leave Certification of Health Care Provider for the Serious Health Condition
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Page 8 lists inpatient care, incapacity plus treatment, pregnancy, chronic conditions and other categories. Incapacity plus treatment means more than three consecutive full calendar days of incapacity with an in-person visit within seven days, plus a second visit within 30 days or a regimen of continuing treatment.
Yes. The form tells the provider to return it to the patient or to mail or fax it to Unum's Absence Management Center. Either way, the employee's complete application is due within 30 calendar days from the start of leave, so the certification should not sit in the office.
Question 5 asks for any other relevant medical facts, giving symptoms and diagnosis as examples, alongside the condition's start date, probable duration, delivery date if pregnant and the treatment plan. Answers should be limited to the condition behind the leave request.