Workers in the District of Columbia who take Paid Family Leave to care for a family member with a serious health condition need this four-page certification. The claimant describes the care or companionship they will give; the family member's health care provider then documents the condition with ICD-10 codes, the leave needed and whether that care is reasonable and necessary. The claim cannot be filed until it is signed.
The claimant completes Part 1 first; the family member's treating licensed health care provider completes all of Part 2, Sections A through E, and signs.
Download the current version from the source each time; forms change without notice.
Family Leave Medical Certification Form
Formulario de certificación médica que justifica la licencia familiar
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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The claimant fills in Part 1, including the family member's name, relationship and the care or companionship they will provide. The doctor or licensed health care provider treating the family member completes Part 2: provider details with license number, the qualifying condition and ICD-10 code, amount of leave, need for care and the signed certification.
At the time of application. DC's Office of Paid Family Leave says claimants must include the medical certification when they apply, and the PFL-FMC instructions say family leave filing can be completed only after the family member's provider has completed and signed the form, so prompt completion matters.