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WA Paid Leave Prenatal Care Medical Certification

Washington's Paid Family and Medical Leave program uses this one-page certification when a pregnant patient applies for medical leave to attend prenatal care or because a pregnancy-related condition keeps them from working. The prenatal care provider confirms the reason and gives exact leave dates. The patient then submits the signed form with their Paid Leave application so the Employment Security Department (ESD) can decide the claim.

Who completes it

The patient fills in Section 1 with name, date of birth and Paid Leave Customer ID. The health care provider completes and signs Section 2, checking prenatal care, incapacity due to a prenatal condition, or both, and adds start and end dates, license number and specialty.

Submitting and payment

How to submit it
The provider returns the completed form to the patient within 7 calendar days of receiving it; the patient uploads it to their Paid Leave account or faxes it to ESD.
Who pays
No fee may be charged: ESD states that providers cannot charge a fee for completing the form.

Good to know

  • Checking the incapacity box for conditions such as severe morning sickness, pre-eclampsia or infections lets ESD approve the full amount of leave the patient is entitled to.
  • If leave covers the rest of the pregnancy, enter the estimated due date as the end date. Entries such as "unknown" or "indeterminate" are not enough to decide eligibility.
  • Corrections are made by crossing out the error, writing the new information and initialing the change. ESD does not accept white-out.
  • Leave after delivery uses other pages of the same packet: the Certification of Birth for the first six weeks and the Medical Certification for Birth Complications for longer recovery.

Get the official form

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

Prenatal Care Medical Certification

Certificado médico de cuidado prenatal

Official pagePDF

Fill it with Vero

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.

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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

Can a provider charge for the Washington prenatal care certification?

No. The Employment Security Department states that health care providers cannot charge a fee for completing Paid Leave certification forms, including this one. The provider completes Section 2 and returns the form to the patient within 7 calendar days of receiving it, and the patient submits it with the leave application.

Is the prenatal care certification available in Spanish?

Yes. The form is printed bilingually, with English and Spanish on the same page, as page 3 of ESD's Pregnancy and Birth Certifications packet updated in June 2024. The packet also contains instructions for health care providers, the Certification of Birth and the Medical Certification for Birth Complications.

Can an FMLA form be used instead of the prenatal care certification?

ESD accepts a Family and Medical Leave Act form or a provider note in place of its own certification, as long as it contains the information required by WAC 192-610-020. The ESD form asks for those items directly: the reason for leave, specific start and end dates, and a signed declaration under penalty of perjury.