CAREGIVER LEAVE LETTER

[Practice name]
[Address]
[Phone and email]

Date issued: [Date]
To: [Caregiver's employer, or To whom it may concern]

Re: Leave for [caregiver's full name] to care for [patient's full name]
Patient's date of birth: [Date]
Relationship to the patient: [e.g. father, daughter, spouse, as told to me by the patient or family]

I am [patient name]'s [role, e.g. treating physician or nurse practitioner]. I last assessed them on [date of the visit].

CONDITION
[Patient name] has a serious medical condition.
[Only if the leave program asks for it and your assessment supports it: e.g. there is a significant risk of death within 26 weeks, or the patient is critically ill and their life is at risk. Otherwise delete this line]
Diagnosis: [Only if the patient agrees; otherwise delete this line]

CARE OR SUPPORT NEEDED
[Patient name] needs care or support from a family member, including [what kind: e.g. getting to treatment, staying with them in hospital, personal care at home, medicines, emotional support, arranging other care].
How often: [Full time, or the days needed, e.g. treatment days and the day after]

PERIOD
From [first date] to [last date].
Review: [Date I will reassess the need for care, or not needed]

CONSENT
[Patient name, or their parent, guardian, or substitute decision-maker] agreed to share this information with [caregiver name]'s employer.

To confirm that this practice issued this letter, call [practice phone]. We will confirm only that the letter is genuine.

[Your name, credentials]
[License or registration number]
[Signature]