DC Paid Family Leave includes up to two weeks of prenatal leave for pregnancy-related medical care, usable in one-day increments, and this form is how the pregnant worker's health care provider certifies it. Prenatal leave covers check-ups, pregnancy-related treatment and diagnostic visits, and doctor-ordered bedrest. The claimant uploads the completed certification when filing for prenatal leave.
The pregnant claimant's licensed health care provider, such as an OB/GYN, midwife, family physician or nurse practitioner, completes and signs the provider part of the form.
Download the current version from the source each time; forms change without notice.
Prenatal Leave Medical Certification Form
Formulario de certificación médica que justifica la licencia prenatal
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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Up to two weeks of paid leave, in one-day increments, for prenatal check-ups, pregnancy-related medical treatment, visits to diagnose a pregnancy-related condition, and bedrest a doctor orders for a pregnancy-related condition. The worker must miss a full workday to receive benefits for that day.
After the first claim with the certification, the worker can request payment for additional visit dates using medical visit slips, visit summaries from the provider, a letter from the provider's office listing care dates, or an updated prenatal medical certification form.