District of Columbia workers applying for Paid Family Leave medical leave for their own serious health condition must have their health care provider complete this three-page form before they can file. The provider identifies the condition and ICD-10 code, checks how it qualifies as serious, from pregnancy and inpatient care to chronic conditions or stillbirth, and estimates continuous, planned or intermittent leave.
The claimant fills in Part 1 (name and date of birth); the claimant's licensed health care provider completes Part 2, Sections A through D, and signs.
Download the current version from the source each time; forms change without notice.
Medical Leave Medical Certification Form
Formulario de certificación médica que justifica la licencia médica
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.
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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Only after the PFL-MMC is completed and signed by the claimant's doctor or licensed health care provider. The claimant must include it at the time of application in the online benefits portal, so a delay in completing Part 2 delays the whole claim.
DC's Benefit Forms page lists only its own certification forms, and its guidance for providers does not mention FMLA forms. The PFL-MMC instructions say the claimant must submit this form through the Paid Family Leave portal, with every section of Part 2 completed.