Form WH-380-E, Certification of Health Care Provider Completed Form Examples and Samples

Explore a detailed example of the WH-380-E Form filled out for an employee with a chronic health condition. This sample provides insight into how to document essential information such as healthcare provider details, diagnosis, treatment frequency, and recommended work schedule changes for FMLA certification purposes.
Form WH-380-E, Certification of Health Care Provider has a moderate Form Complexity Index of 59/100 — Instafill’s AI completes it in under a minute.
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Completed WH-380-E Form for an employee with a chronic health condition

WH-380-E Example – Employee with Chronic Health Condition

How this form was filled:

This example highlights the completion of Form WH-380-E for an employee suffering from a chronic health condition. Essential details such as the healthcare provider's contact information, the condition's expected duration, and the recommended work schedule changes are documented.

Information used to fill out the document:

  • Employee's Name: Jane Smith
  • Healthcare Provider's Name: Dr. Emily Johnson
  • Provider's Address: 456 Health St, Wellness City, USA
  • Phone Number: 555-123-4567
  • Diagnosis: Chronic Migraine
  • Condition Duration: Indefinite
  • Treatment Frequency: Twice a month
  • Recommended Work Schedule Changes: Flexible work hours as needed
  • Signature: Dr. Emily Johnson
  • Date Signed: 01/20/2025

What this filled form sample shows:

  • Comprehensive healthcare provider information including address and contact details
  • Detailed diagnosis and treatment plan description
  • Specific duration and frequency of treatment outlined
  • Clear explanation of accommodations and work schedule changes

Form specifications and details:

Use Case: Employee with a chronic health condition requiring flexible work accommodations
Categories: CAR forms, certification forms, health care forms, health forms, L.A. Care forms
Completed WH-380-E Form for an employee with a chronic health condition