New Jersey Family Leave Insurance claims use the FL-1. When an employee takes leave to care for a seriously ill family member, Part C Section 1 is the care recipient's medical certificate: diagnosis with ICD code, whether full-time care is needed, and when care started and should end. Bonding claims skip Part C entirely.
The claimant completes Parts A and B, and Part D for a partial schedule; the care recipient's licensed healthcare provider completes Part C Section 1, and the care recipient signs Section 2 authorizing disclosure.
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Claim for Family Leave Benefits (Part C - Healthcare Provider's Certification for care of a family member)
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No. Part C is completed only when the claimant is caring for an ill family member. Bonding claims for a new child do not need the care recipient's medical certificate, so a provider is involved only in caregiving claims under New Jersey Family Leave Insurance.
The care recipient. Section 2 authorizes the care recipient's physicians to disclose current health information to the claimant and the Division of Family Leave Insurance. If the care recipient cannot sign, an authorized representative signs under parental right, power of attorney or court order.
Yes, when the claimant filed online. The care recipient's provider uses the claimant's Form ID to complete the FLI medical statement (M-01) on the Division's secure website and receives immediate confirmation. Paper Part C is used only with a paper FL-1.