Form WH-380-E, Certification of Health Care Provider Instructions

The health care provider must sign here to certify the information provided in this form.

Enter the approximate date when the medical condition started or is expected to start.

Provide your best estimate of how long the medical condition has lasted or is expected to last.

Check this box if the patient was incapacitated for a continuous period of time due to the condition (including time for treatment and/or recovery).

Check this box if the patient will be incapacitated for a continuous period of time due to the condition (including time for treatment and/or recovery).

Enter the estimated beginning date of the employee’s continuous period of incapacity. Fill only if 'Was incapacitated (continuous period)', 'Will be incapacitated (continuous period)' is selected (any).

Enter the estimated end date of the employee’s continuous period of incapacity. Fill only if 'Was incapacitated (continuous period)', 'Will be incapacitated (continuous period)' is selected (any).

Check this box if, due to the condition, the employee was not able (in the past) to perform one or more essential job functions.

Check this box if, due to the condition, the employee is currently not able to perform one or more essential job functions.

Check this box if, due to the condition, the employee will not be able (in the future) to perform one or more essential job functions.

Enter the full name of the employee who is seeking FMLA leave.

Enter the employee's full name.

Enter the employee's full name.

Enter the employee’s job title/position as it appears in the employer’s records.

Check this box if the employee’s job description is included as an attachment with this form.

Check this box if the employee’s job description is not included as an attachment with this form.

Enter the employee's first (given) name.

Enter the employee's middle name or middle initial.

Enter the employee's last (family) name.

Enter the employee’s normal work schedule (e.g., days of the week and typical hours worked).

Enter the name of the employee’s employer requesting the medical certification.

Enter the date the employer requested the medical certification.

Describe at least one essential job function the employee is not able to perform due to the condition. Fill only if 'Was not able', 'Is not able', 'Will not be able' is 'Yes' (any).

Provide a narrative statement describing the employee’s essential job functions for their position.

Enter the full name of the health care provider.

Enter the health care provider’s business mailing address.

Enter the type of practice or the provider’s medical specialty.

Enter the health care provider’s telephone number.

Enter the health care provider’s fax number.

Enter the health care provider’s email address.

Enter the date on which the health care provider signed this form.

Check this box if the patient’s condition involves incapacity plus treatment (e.g., outpatient surgery, strep throat).

Check this box if the patient has already been incapacitated for more than three consecutive full calendar days due to the condition.

Check this box if the patient is expected to be incapacitated for more than three consecutive full calendar days due to the condition.

Enter the date the patient became (or is expected to become) incapacitated for more than three consecutive full calendar days. Fill only if 'Incapacity plus Treatment' is 'Yes'.

Enter the date the period of incapacity ended (or is expected to end). Fill only if 'Incapacity plus Treatment' is 'Yes'.

Check this box if the patient was seen by a health care provider on the date(s) listed.

Check this box if the patient will be seen by a health care provider on the date(s) listed.

List the date(s) on which the patient was seen or will be seen by a health care provider for this condition (first line). Fill only if 'Incapacity plus Treatment' is 'Yes'.

List any additional date(s) on which the patient was seen or will be seen by a health care provider for this condition (second line). Fill only if 'Incapacity plus Treatment' is 'Yes'.

Check this box if the condition has resulted in a course of continuing treatment under a health care provider’s supervision.

Check this box if the condition has not resulted in a course of continuing treatment under a health care provider’s supervision.

Check this box if the patient will be admitted for an overnight stay in a hospital, hospice, or residential medical care facility.

Check this box if the patient has already been admitted for an overnight stay.

Check this box if the patient is expected to be admitted for an overnight stay in the future.

Enter the date or dates on which the patient was admitted or is expected to be admitted for an overnight inpatient stay. Fill only if 'Inpatient Care' is 'Yes'.

Check this box if it was medically necessary for the employee to be absent from work on an intermittent/episodic basis due to the condition.

Check this box if it is currently medically necessary for the employee to be absent from work on an intermittent/episodic basis due to the condition.

Check this box if it will be medically necessary for the employee to be absent from work on an intermittent/episodic basis due to the condition.

Enter the estimated number of episodes of incapacity expected to occur over the next 6 months per selected time unit (day, week, or month). Fill only if 'Was medically necessary (intermittent absence)', 'Is medically necessary (intermittent absence)', 'Will be medically necessary (intermittent absence)' is selected (any).

Enter the estimated length of time each episode of incapacity is expected to last, with the unit indicated as hours or days. Fill only if 'Was medically necessary (intermittent absence)', 'Is medically necessary (intermittent absence)', 'Will be medically necessary (intermittent absence)' is selected (any).

Check this box if the estimated number of episodes is provided per day. Fill only if 'Was medically necessary (intermittent absence)', 'Is medically necessary (intermittent absence)', 'Will be medically necessary (intermittent absence)' is selected (any).

Check this box if the estimated number of episodes is provided per week. Fill only if 'Was medically necessary (intermittent absence)', 'Is medically necessary (intermittent absence)', 'Will be medically necessary (intermittent absence)' is selected (any).

Check this box if the estimated number of episodes is provided per month. Fill only if 'Was medically necessary (intermittent absence)', 'Is medically necessary (intermittent absence)', 'Will be medically necessary (intermittent absence)' is selected (any).

Check this box if the estimated length of each episode is provided in hours. Fill only if 'Was medically necessary (intermittent absence)', 'Is medically necessary (intermittent absence)', 'Will be medically necessary (intermittent absence)' is selected (any).

Check this box if the estimated length of each episode is provided in days. Fill only if 'Was medically necessary (intermittent absence)', 'Is medically necessary (intermittent absence)', 'Will be medically necessary (intermittent absence)' is selected (any).

Enter the deadline date by which the medical certification must be returned. Fill only if 'Certification Request Date' is provided; set this date at least 15 calendar days after it (unless not feasible).

Check this box if the condition is chronic and requires periodic visits for treatment at least twice per year.

Check this box if the condition is permanent or long term and requires continuing supervision by a health care provider.

Check this box if the condition requires multiple treatments by a health care provider (such as chemotherapy, restorative surgery, or similar treatment series).

Check this box if none of the listed condition categories on this page apply.

Provide a brief description of any other relevant medical facts related to the condition(s) for which the employee seeks FMLA leave (e.g., use of a nebulizer, dialysis).

Check this box if, due to the condition, the patient has already had planned/scheduled medical treatments or visits on the listed date(s).

Check this box if, due to the condition, the patient is expected to have planned/scheduled medical treatments or visits on the listed future date(s).

Enter the first date or range of dates for the patient’s planned medical treatment(s) or scheduled medical visit(s). Fill only if 'Had planned medical treatment(s)', 'Will have planned medical treatment(s)' is selected (any).

Enter any additional date(s) or range of dates for the patient’s planned medical treatment(s) or scheduled medical visit(s). Fill only if 'Had planned medical treatment(s)', 'Will have planned medical treatment(s)' is selected (any).

Check this box if the medical condition for which leave is requested is pregnancy.

Enter the expected delivery date for the pregnancy. Fill only if 'Pregnancy' is 'Yes'.

Enter the date the employee will begin working a reduced schedule due to the medical condition.

Enter the date the employee is expected to stop working a reduced schedule due to the medical condition.

Describe the reduced schedule the employee is able to work (e.g., hours per day and/or total hours per week).

Check this box if the patient has already been referred to other health care provider(s) for evaluation or treatment due to the condition.

Check this box if the patient is expected to be referred to other health care provider(s) for evaluation or treatment due to the condition.

Enter the nature of the evaluation or treatment the patient is being referred for (e.g., cardiologist, physical therapy). Fill only if 'Was referred to other health care provider(s)', 'Will be referred to other health care provider(s)' is selected (any).

Enter your best estimate of the date the referred evaluation or treatment will begin. Fill only if 'Was referred to other health care provider(s)', 'Will be referred to other health care provider(s)' is selected (any).

Enter your best estimate of the date the referred evaluation or treatment will end. Fill only if 'Was referred to other health care provider(s)', 'Will be referred to other health care provider(s)' is selected (any).

Describe your best estimate of the duration and frequency of the referred treatment(s), including any recovery period(s) (e.g., 3 days/week). Fill only if 'Was referred to other health care provider(s)', 'Will be referred to other health care provider(s)' is selected (any).