Massachusetts Paid Family and Medical Leave requires this certification when an employee applies for paid medical leave for their own serious health condition, including pregnancy, prenatal care and recovery from childbirth. The provider confirms which serious health condition criteria apply, names at least one essential job function the patient cannot perform, and estimates continuous, reduced or intermittent leave. The Department of Family and Medical Leave (DFML) uses it to approve or deny benefits and shares it with the employer.
The employee completes Section 1 (name, date of birth, last four digits of the SSN or ITIN, occupation and optional application number) and writes their name on the later pages. The health care provider completes Sections 2 to 4, questions 8 to 24, and signs and dates on page 6.
The employee completes this section: name, and the name on official documents such as a driver's license or W-2 if different, phone, date of birth, last four digits of the Social Security number or ITIN, occupation and, optionally, the application number (NTN). DFML uses Section 1 to match the certification to the rest of the application. The employee also writes their name at the top of the remaining pages before handing the form to the provider.
Check every criterion that applies, including for mental health: inpatient care; incapacity for more than three consecutive full calendar days plus either two or more visits within 30 days or one visit and a regimen of care; a chronic condition treated at least twice a year that may cause periodic absences; a long-term condition needing ongoing supervision; or multiple treatments that prevent incapacity. Page 2 defines these terms. If none apply, the patient is not eligible for PFML.
Question 9 asks for the medical facts about the condition, such as symptoms, prescriptions and referrals for evaluation or treatment. Question 10 asks for at least one essential job function the patient cannot perform, from specific tasks like sitting at a computer, manual labor or making decisions to the ability to work at all. Question 11 asks whether the condition is a job-related injury. DFML relies on these answers to approve or deny the claim.
Answer whether the condition relates to pregnancy or recovery from childbirth. If yes, estimate the weeks needed for pregnancy or prenatal care and for recovery from childbirth or postnatal care, and give the expected delivery date. Leave for pregnancy must still meet the serious health condition definition. Bonding leave needs no form, only proof of birth, and medical leave does not reduce it within the 26-week benefit-year maximum.
Check continuous leave when the patient is or will be completely unable to work for consecutive, uninterrupted days, and give the estimated beginning and end dates of incapacity in mm/dd/yyyy format. Base the estimate on your medical knowledge, experience and examination. Do not write unknown or TBD. Approved leave will not run past the dates you certify, so a new certification may be needed if recovery takes longer.
For reduced leave, give the date range and the hours the patient cannot work, for example 5 hours a day, up to 25 hours a week. For intermittent leave, give the date range over the next six months, how often episodes of incapacity will occur per day, week or month, and how many hours or days each lasts. Check every type that applies; leave can combine continuous, reduced and intermittent schedules.
Sign and date to certify that the information is true, that you examined the patient, and that you are a health care provider authorized to certify the condition under the page 2 definition. Print your name and title, the certificate or license number with state or country, area of practice or specialty, practice name, address and office phone; fax is optional. The form will not be accepted without a license number. Review pages 3 to 6 before sending.
Download the current version from the source each time; forms change without notice.
Certification of Your Serious Health Condition
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.
Sources for this guide
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
A licensed physician or osteopath, dentist, podiatrist, clinical psychologist, optometrist, chiropractor (limited to spinal manipulation for a subluxation shown on X-ray), nurse practitioner, nurse-midwife, clinical social worker or physician assistant practicing within their scope, or a listed Christian Science practitioner. Providers licensed in another country can also certify. The provider completes Sections 2 to 4 and signs.
By e-fax to DFML or through the organization's Epic platform, sending the entire form including the employee's Section 1. If the office cannot send it, it returns the whole form to the patient, who uploads it to their paid leave account. Including the application number (NTN) in Section 1 helps DFML match it to the right application.
No. DFML publishes this certification form in English only. Its Health Care Provider Toolkit for PFML is available in Spanish, Portuguese, Chinese and Haitian Creole, which can help explain the process to patients, but the provider still completes the English form.
Give your best estimate of start and end dates, hours per week, or episode frequency and duration, based on your knowledge and examination of the patient. DFML says terms like unknown or TBD may cause delays and revisions. Approved leave cannot exceed what you certify, and a new certification may be needed if circumstances change.