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Massachusetts PFML Family Serious Health Condition Form

Massachusetts Paid Family and Medical Leave applicants need this DFML certification to take leave caring for a family member with a serious health condition, including one related to military service. The family member's provider certifies which serious-health-condition criteria apply, describes the medical facts and the care needed, and estimates continuous, reduced or intermittent leave. DFML uses it to decide eligibility.

Who completes it

The employee completes Sections 1 and 2: their own details, the family relationship and an attestation that the family member authorized sharing the information. The family member's health care provider completes Sections 3 to 5, questions 15 to 30, and signs with a license number.

Submitting and payment

How to submit it
The provider sends the entire form to DFML by e-fax or through their organization's Epic platform, or returns it to the patient, who uploads it to their paid leave account. If the applicant starts the application first, the NTN claim number can go on the form.

Good to know

  • Question 15 lists the qualifying criteria, such as inpatient care, more than three days of incapacity with visits, or chronic or long-term conditions. If none apply, the employee is not eligible.
  • For continuous, reduced or intermittent leave, give best-estimate dates, hours or episode frequency and duration. The form warns that writing unknown or TBD causes delays and revisions.
  • Approved leave will not exceed the frequency and duration certified, and a new certification may be needed if circumstances change. DFML does not accept the form without a license number.
  • Bonding leave, leave for the applicant's own condition and leave to manage affairs for an active service member do not use this form. Version 6.0 is dated March 2026.

Get the official form

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

Certification of Your Family Member's Serious Health Condition

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

Who can sign the Massachusetts family serious health condition certification?

A licensed physician or osteopath, dentist, podiatrist, clinical psychologist, optometrist, nurse practitioner, nurse-midwife, clinical social worker or physician assistant within their scope of practice. Chiropractors qualify only for manual spinal manipulation of an X-ray-confirmed subluxation. Christian Science practitioners listed in Boston and authorized providers practicing outside the United States also qualify.

Can the provider send the form directly to DFML?

Yes, and DFML calls it the simplest route. After confirming the patient has authorized sharing medical information with the applicant, the provider e-faxes the entire form to DFML or transmits it through the organization's Epic platform. If the provider cannot send it, the whole form goes back to the patient to upload.

What kind of care does the provider describe on the form?

Question 18 asks whether the employee must take time off work to care for the patient, and question 19 asks what care the employee will give. DFML's examples include meeting medical, hygienic, nutritional or safety needs the patient cannot manage alone, such as transportation to the doctor.