Colorado's FAMLI program uses this certification to confirm that a worker, or the family member they will care for, has a serious health condition, and to set how long leave may last. The provider also selects an Absence Parameter Limit of 7 or 30 days for the claim. It is completed online in My FAMLI+ or printed from within the claim.
A health care provider licensed, certified or registered under federal or Colorado law to provide medical or emergency services completes the whole certification for the claimant or the family member.
Download the current version from the source each time; forms change without notice.
Serious Health Condition Form
Colorado Department of Labor and Employment, Division of Family and Medical Leave Insurance (FAMLI) takes this form through its online services or your EMR, so there is no PDF to fill. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
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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A provider registers in My FAMLI+, verifies their license, and can then certify the claim entirely online, including the leave duration and Absence Parameter Limit. Staff can be delegated to help. Providers who are not registered sign the paper version the claimant prints from the claim.
Any U.S.-licensed health care provider, meaning a person licensed, certified or registered under federal or Colorado law to provide medical or emergency services. The provider certifies the condition of the claimant, or of the family member for care leave.