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Oregon OFLA-Only Health Care Provider Certification

BOLI's OFLA-only template certifies the two kinds of Oregon Family Leave Act leave that do not run through federal FMLA: pregnancy and prenatal care, including fertility or infertility treatment, and sick child leave. The provider describes the medical facts, the expected duration and whether full-time or intermittent leave is needed. The employee returns it to the employer.

Who completes it

The employee's or child's health care provider completes the whole form after the employee and patient names are entered.

Submitting and payment

How to submit it
The provider gives the completed form back to the employee, who passes it to the employer.
Who pays
The template sets no fee and names no payer for the provider's certification.

Good to know

  • The pregnancy category includes childbirth, pregnancy termination, prenatal care absences and fertility or infertility treatment, with incapacity before or after the birth.
  • Sick child leave covers any illness, injury or condition of the employee's child that needs home care, even when it is not a serious health condition, so pediatric practices see it often.
  • For a child's care, item 8 asks whether the child needs help with basic medical or personal needs, safety or transportation, or would benefit from the parent's presence.
  • For leave that qualifies under both OFLA and FMLA, BOLI offers a separate combined template with seven condition categories.

Get the official form

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

Oregon Family Medical Leave Health Care Provider Certification

Official pageWord file

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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

Does the Oregon OFLA-only certification cover fertility treatment?

Yes. Category 1, pregnancy and prenatal care, explicitly includes fertility or infertility treatment, along with incapacity from pregnancy or pregnancy-related illness before or after the birth, childbirth, pregnancy termination and absences for prenatal care.

Can a minor childhood illness qualify for OFLA sick child leave?

Yes, when the child needs home care. The form defines sick child leave as any illness, injury or condition of the employee's child requiring home care, covering both serious and non-serious health conditions, so a short illness can be certified on this template.

Is the BOLI OFLA-only certification a PDF?

No. BOLI posts it as a Word template on its Oregon Family Leave Act page, and employers may adapt it. The current file was last updated in December 2025. It is completed by the provider and returned to the employee.