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Guardian MA PFL-4: Family Care Provider Certification

Guardian uses Form MA PFL-4 when an employee covered by its private Massachusetts paid family leave plan needs time off to care for a family member with a serious health condition. The care recipient's provider confirms the diagnosis, when care starts and ends, and the care schedule. The employee files it with the MA PFL-1 claim form so Guardian can decide the benefit.

Who completes it

The employee fills in their own and the care recipient's identifying details at the top; the care recipient's health care provider answers questions 1 to 8 and signs. The employer completes Part B of the separate MA PFL-1 claim form.

Submitting and payment

How to submit it
The provider returns the signed MA PFL-4 to the employee, who sends it to Guardian's Paid Leave Claims unit with the MA PFL-1 by mail, fax or email; Guardian asks for the claim within 30 days after the leave starts.
Who pays
The packet sets no fee and names no payer for the provider's certification.

Good to know

  • Before the provider completes PFL-4, the care recipient signs Form MA PFL-3 authorizing release; the provider keeps PFL-3 on file and it is not sent to Guardian.
  • Question 1 asks whether the patient needs care from this employee. Guardian's definition of care includes emotional support, visitation, transportation, arranging a change in care and help with daily living.
  • The ICD-10 code is optional, but the diagnosis, condition start date, first date care is needed, expected end of care and the care schedule all need answers.
  • Question 8 asks whether the condition relates to or was aggravated by the family member's military service; military qualifying events use the separate MA PFL-5.

Get the official form

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

Massachusetts Paid Family Leave Claim Packet – health care provider certification for a family member (Form MA PFL-4)

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

Who keeps the Guardian MA PFL-3 release?

The care recipient, or an authorized representative, completes Form MA PFL-3 and gives it to their health care provider with the PFL-4. The provider retains PFL-3, and Guardian's instructions say not to return it. The release covers only information about the current condition and ends after one year unless revoked sooner.

Is the ICD-10 code required on the Guardian MA PFL-4?

No. The primary ICD-10 code field is marked optional. The provider still enters the diagnosis, the date the condition began, the first date care is needed, the expected date care will no longer be needed and a schedule of the dates, days and hours of care.

Does Guardian's MA PFL-4 replace the state DFML form?

For employees whose employer has a Guardian-approved private plan, yes. The claim form states that the Guardian plan replaces the state plan, so the claim and the provider certification go to Guardian instead of the Massachusetts Department of Family and Medical Leave.