Washington Paid Family and Medical Leave lets a health care provider designate an authorized representative for a patient who cannot handle the program's administrative steps or name a representative themselves. The provider attests that the designation is in the patient's best interest. The form is not posted online; ESD's Paid Leave Customer Care Team supplies it for each case.
The patient's health care provider completes the designation and attestation; the patient does not complete a section because they are unable to act for themselves.
Download the current version from the source each time; forms change without notice.
Designated Authorized Representative form (health care provider attestation)
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.
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When the patient is incapable of completing Paid Family and Medical Leave administrative requirements and of designating an authorized representative on their own. The provider must attest to both facts and that the designation is in the patient's best interest.
From ESD's Paid Leave Customer Care Team. ESD does not post the form on its website; its health care provider page directs providers to call the Customer Care Team, which supplies the form for the specific patient.