Minnesota Paid Leave uses this form only for continuous medical leave before or after giving birth, meaning one stretch of time completely off work. The provider gives the due date or date of birth and estimates the weeks of leave needed before birth, if medically beneficial, and to recover from birth. When the child has already been born, the same form also certifies bonding leave eligibility.
The applicant completes Section 1 and signs. The treating provider, often an OB-GYN, midwife, nurse practitioner or primary care physician, completes Section 2 (leave information) and Section 3 (provider certification) and returns the form to the patient.
Download the current version from the source each time; forms change without notice.
Minnesota Paid Leave Pregnancy-related Medical 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, when the child has already been born. In that case the form certifies eligibility for both medical leave and bonding leave. If the child has not been born yet, it certifies medical leave only, and the applicant uploads a document proving the birth before bonding leave can begin.
No. It certifies only continuous leave, one stretch completely off work, before or after the birth. A patient who will work reduced hours or needs intermittent time off uses the Minnesota Paid Leave Medical Leave certification form, which has reduced-schedule and intermittent leave sections.
Whether the child has been born, with the date of birth or the expected due date; whether pre-birth leave is medically beneficial and about how many weeks; and whether recovery leave is medically beneficial and about how many weeks. The provider then adds name, specialty, office contact and license number and signs.