Minnesota employers can provide paid family and medical leave through a private plan insured by Unum, and claims under those plans use this eight-page packet. The provider of the employee or of a family member certifies the serious health condition on pages 6 and 7: onset, duration, job relation, effect on work, the condition category and an estimate of the leave needed.
The employee and employer complete pages 1 to 5 and the top of page 6. The health care provider of the employee or family member answers questions 1 to 7 on pages 6 and 7 and signs with printed name, practice type, phone and fax.
Download the current version from the source each time; forms change without notice.
Minnesota PFML Certification of Health Care Provider
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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When the patient's employer meets Minnesota paid family and medical leave obligations through a private plan insured by Unum. Claims under such a plan are decided by Unum, so the provider completes Unum's certification pages rather than a state form.
The form defines incapacity as an inability to perform regular work, attend school or perform regular daily activities because of a serious health condition, its treatment or recovery. Provider estimates should be specific; the instructions say lifetime, unknown or indeterminate may not be enough to determine coverage.
Yes. The employee marks the patient's relationship at the top of page 6 (self, minor child, adult disabled child, parent, spouse or other) and describes the care they will give. The provider treating the person with the condition completes the medical questions.