Minnesota Paid Leave applicants use this form for caring leave when a family member or someone close to them has a serious health condition. The patient's provider certifies the condition, estimates when it started and how long it will last, sets out continuous, reduced or intermittent care, and confirms the care the applicant will give, such as help with basic needs, transportation or psychological comfort.
The applicant completes Section 1 on the family member who needs care and Section 2 for up to three caregivers, each of whom signs. The family member's healthcare provider completes Sections 3 to 5 (health condition, leave information and provider certification) on pages 9 to 13 and returns the form.
Download the current version from the source each time; forms change without notice.
Minnesota Paid Leave Caring Leave Certification Form
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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Yes, if it includes all the required information. Minnesota Paid Leave accepts FMLA certification forms that are complete and considers employer-developed forms case by case, but it recommends its own forms. Paid Leave covers more situations than FMLA, so some caring leave that qualifies in Minnesota may not qualify for FMLA.
The provider checks whether the patient needs help with basic medical, hygiene, nutrition, mobility or safety needs, transportation, psychological comfort or other care. The provider then chooses continuous, reduced-schedule or intermittent care, with start and end dates and, for intermittent care, how often episodes occur and how long they last.
A healthcare provider licensed, certified or otherwise authorized to certify the patient's condition within their scope of practice. The form lists physicians, physician assistants, nurse practitioners, nurse-midwives, licensed midwives, dentists, optometrists, podiatrists, clinical psychologists, clinical social workers and Minnesota-defined mental health professionals and alcohol and drug counselors, among others.