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Paid Leave Oregon Serious Health Condition (PL 811)

Paid Leave Oregon asks for this verification when a claimant applies for medical leave for their own serious health condition or family leave to care for a family member's. The provider checks which serious health condition categories apply, gives the condition's start and expected end dates, and estimates how many days a week an intermittent condition will affect the patient.

Who completes it

The claimant completes Part A and, for family leave, Part B with the family member's details; the patient's authorized health care provider completes Part C on the condition and need for leave and signs Part D.

Submitting and payment

How to submit it
The provider returns the form to the claimant, who uploads it to Frances Online or mails or faxes it to Paid Leave Oregon; it may not be signed more than 60 days before the leave starts.
Who pays
The form sets no fee and names no payer for the provider's certification.

Good to know

  • Part C needs a diagnosis or a description of symptoms or required treatment; the ICD-10 code is optional, and 'unknown' or 'indeterminate' end dates are not accepted.
  • Checking 'None of the above' tells Paid Leave Oregon the condition does not meet the serious health condition definition, so the claim will not qualify.
  • For chronic or permanent conditions, give dates for the current episode; intermittent need is estimated as a maximum of one to seven days per week.
  • Paid Leave Oregon also accepts BOLI's OFLA/FMLA certification or other provider documentation with the required elements. Versions exist in Spanish, Russian, Chinese, Vietnamese, Korean and Arabic.

Get the official form

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

Verification of Serious Health Condition Form

Formulario de verificación de condición médica grave

Official pagePDFVersión en español

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Who can sign Paid Leave Oregon's Verification of Serious Health Condition?

A health care provider as defined in OAR 471-070-1000 who is primarily responsible for the patient's care: physicians, physician associates, nurse practitioners, registered nurses, psychologists, regulated social workers, optometrists, dentists, naturopathic physicians, direct entry midwives and, within limits, chiropractic physicians. Spiritual-means practitioners also qualify.

Can PL Form 811 be completed in advance?

Only up to 60 days before the expected leave start date; Paid Leave Oregon rejects forms signed earlier. The form also cannot be altered after signing, so a mistake means completing a new copy from the Resources page at paidleave.oregon.gov.

Does PL Form 811 cover organ donation and pregnancy?

Yes. Part C has a category for absence to donate an organ, body part or tissue, covering preoperative or diagnostic services, surgery, post-operative treatment and recovery. Pregnancy, childbirth, miscarriage, stillbirth and prenatal care have their own category, with the delivery date requested.