New York Paid Family Leave lets employees take paid time off to care for a family member with a serious health condition, and PFL-4 is the medical proof the insurance carrier reviews. The care recipient's provider confirms that the patient needs the employee's care, gives the diagnosis and key dates, and estimates days of care per week or month. The employee files it with PFL-1.
The care recipient's health care provider completes the Care Recipient (Patient) Information and Health Care Provider Information sections and signs. The employee fills in the identification lines at the top of each page, and the care recipient signs the separate PFL-3 release, which the provider keeps on file.
The employee enters their name, date of birth, any other last names used at work, Social Security number or taxpayer ID, mailing address, and the care recipient's name and date of birth at the top of page 1, then repeats both names and dates of birth at the top of page 2. Separately, the care recipient completes the PFL-3 release and gives it to you to keep on file.
Question 1 asks whether the patient requires care by the employee requesting Paid Family Leave; if No, skip to Health Care Provider Information. The form defines providing care broadly: necessary physical care, emotional support, visitation, assistance in treatment, transportation, arranging for a change in care, help with essential daily living matters, and personal attendant services.
Enter the primary ICD-10 code (optional but recommended), the diagnosis, the date the condition commenced, the first date care is needed and the expected date the patient will no longer require care. Question 7 asks for the estimated number of days per week or days per month the patient requires care; PFL is taken in full-day increments, either all at once or intermittently.
Give your name, provider type (MD, DO, DPM, DC, dentist, PA, NP, licensed psychologist, LMSW or LCSW, or other), mailing address, telephone, fax, email if available, the state or country where you are licensed, your specialty and license number. Providers practicing outside New York or outside the U.S. must hold a valid license where they practice.
Sign and date to attest that the information is based on your professional assessment within your licensed scope of practice. The section carries a fraud warning about knowingly filing materially false information. Return the form to the employee, who sends it with PFL-1 to the carrier; the program calls timely completion by the provider critical because of the 30-day filing deadline.
Download the current version from the source each time; forms change without notice.
Health Care Provider Certification for Care of Family Member with Serious Health Condition
Certificado de Proveedor de Atención Médica para el Cuidado de un Miembro de la Familia con un Problema de Salud Grave
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.
Sources for this guide
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Licensed providers acting within their scope of practice: physicians, physician assistants, nurse practitioners, registered professional nurses, psychologists, licensed clinical social workers, mental health practitioners, chiropractors, dentists, podiatrists, optometrists, physical and occupational therapists, speech-language pathologists, audiologists and midwives. Providers outside New York, including abroad, need a valid license where they practice.
No. Question 2, the primary ICD-10 code, is marked optional, although the instructions recommend providing it. The diagnosis in question 3 is expected, along with the date the condition began, the first date care is needed, the expected date care ends, and the estimated days per week or month of care.
Yes. The Paid Family Leave program says a provider may decline when the request is not medically supported or the family member does not have a serious health condition. The PFL-4 instructions also allow declining if the provider believes the patient is the victim of abuse or neglect caused by the employee requesting leave.
Yes. The family care package containing PFL-1, PFL-3 and PFL-4 is published in Spanish and in Russian, Polish, Chinese, Italian, Haitian Creole, Korean, Bengali, Arabic, Yiddish, French and Urdu. Whatever the language, the provider returns the completed form to the employee rather than to the carrier.