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Guardian MA PML-1 Part B Medical Certificate

When an employee covered by a Guardian private plan takes Massachusetts paid medical leave for their own condition, including pregnancy, the claim is filed on Guardian's MA PML-1. Part B, the Medical Certificate, is where the treating doctor records the diagnosis, the leave dates approved and the expected recovery date. Guardian decides the claim from the complete packet.

Who completes it

The employee completes Part A and the employer completes Part C, plus an STD-PML supplement if Guardian short-term disability also applies. The treating physician completes Part B, the Medical Certificate, after the leave begins and signs it with license number and specialty.

Submitting and payment

How to submit it
The employee sends all parts together, with the signed GG-013843 PML authorization, to Guardian's Paid Leave Claims unit by mail, fax or email within 30 days after the medical leave starts.
Who pays
The packet sets no fee and names no payer for completing the Medical Certificate.

Good to know

  • Part B asks for an ICD code plus clinical data supporting the diagnosis and restrictions, the first date the patient could not work, and the inclusive dates the provider approves.
  • For intermittent leave, enter hours per weekday (for example 8 on Monday, 0 on Tuesday). Guardian considers intermittent benefits only after a 7-day waiting period is met.
  • Pregnancy claims ask for the estimated or actual delivery date, any complications, and how a pregnancy ended: normal delivery, C-section, miscarriage or abortion.
  • If the employee also has Guardian short-term disability, this one submission can open both claims, though each plan applies its own eligibility rules. Revision 10/20 is current.

Get the official form

Download the current version from the source each time; forms change without notice.

Massachusetts – Paid Medical Leave Claim Form (Part B Medical Certificate)

Official pagePDF

How this list is checked

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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Frequently asked questions

When should the doctor complete Part B of the Guardian MA PML-1?

The form says the Medical Certificate is completed by the doctor after the leave begins. That timing lets the provider record the actual first date the patient could not work, the period of care so far and the dates being approved, while the employee still files within 30 days of the leave start.

Does Guardian's MA PML-1 need an original signature?

The Part B signature line is labeled as requiring the doctor's original signature, next to the printed name and medical degree, license number and state, address and specialty. The typed-name option printed in the packet applies to the claimant's own signatures, not to the Medical Certificate.

What else does the Guardian Medical Certificate ask?

Beyond diagnosis and dates, Part B asks about emergency room care, hospitalization or rehab, any specialist involved, the type and date of surgery and whether it is cosmetic only, whether the condition is work related, whether the patient was referred, and whether the patient can manage their own affairs.