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New Hampshire PFML Certification Form (MetLife)

New Hampshire's Paid Family and Medical Leave plan is a voluntary insured program administered by MetLife, and this form certifies the serious health condition behind a claim, whether the employee's own or a family member's. A clinician meets it when an NH PFML participant needs the diagnosis, treatment dates, expected duration and any intermittent schedule documented for MetLife.

Who completes it

The employee completes Section 1; the patient's health care provider completes Section 2, Certification of Serious Health Condition, on pages 2 to 4, covering diagnosis or ICD-10 code, hospitalization, expected duration and leave schedule.

Submitting and payment

How to submit it
The completed form goes back to MetLife by mail, by fax or by upload to MetLife MyBenefits.

Good to know

  • MetLife returns certifications as incomplete when duration answers say 'lifetime', 'unknown' or 'as needed', so give estimated end dates and frequencies.
  • Intermittent leave under NH PFML has a 4-hour minimum, which matters when estimating how long each episode or appointment absence lasts.
  • MetLife may accept a federal FMLA form (WH-380-E or WH-380-F), a doctor's note or an Attending Physician Statement if it contains the same information.
  • NH PFML covers employer groups that buy the plan, state employees and individuals who enroll through the individual pool. Revision 01/24 is current.

Get the official form

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

New Hampshire Paid Family & Medical Leave Certification Form

Official pagePDF

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

Is New Hampshire PFML a state-run program like Massachusetts?

No. New Hampshire's plan is voluntary insurance administered by MetLife for the State of New Hampshire. Coverage comes through employers that purchase it, through state employment or through the individual pool, and MetLife handles the claim and this certification.

Will MetLife accept a WH-380 for New Hampshire PFML?

It may. The New Hampshire program notes that MetLife can accept an FMLA certification such as the WH-380-E or WH-380-F, a doctor's note or an Attending Physician Statement, provided it carries the same information as the state's certification form.

What answers make the NH PFML certification incomplete?

Durations written as 'lifetime', 'unknown' or 'as needed' are returned as incomplete. The provider should give estimated start and end dates and, for intermittent leave, the expected frequency and length of episodes, keeping in mind the 4-hour minimum for intermittent leave.