Instructions for Certification of Health Care Provider for Family Member’s Serious Health Condition (WH-380-F)
Under the Family and Medical Leave Act (FMLA), a qualified employee can take up to 12 weeks of unpaid leave to tend an immediate family member’s serious medical situation, ranging from a heart attack to pregnancy and childbirth.
This means that a new father could take time away from his job to tend to his spouse or newborn child without fear of losing his job or being demoted just for taking leave.
When an employee decides to request leave to tend to a family member, his or her employer may require written certification, along with other FMLA forms, to verify that the relative is, in fact, a relative and has a serious medical condition covered by the Act.
The official Department of Labor website has all the necessary FMLA forms available for download, including the Certification of Health Care Provider for Family Member’s Serious Health Condition, or form WH-380-F.
According to the DOL, it should take about 20 minutes to complete form WH-380-F, and an employer needs to retain the submitted form for at least three years.
Certification of Health Care Provider for Family Member’s Serious Health Condition (WH-380-F) Section I: To be Completed by the Employer
The first section gives some basic instructions and only asks for the employer’s name and contact information. This section of the WH-380-F form needs to be filled out before it is turned over to the employee.
Certification of Health Care Provider for Family Member’s Serious Health Condition (WH-380-F) Section II: To be Completed by the Employee
The second section starts off by asking for the employee’s name and the name of the family member with the serious medical condition. Next, the employee needs to provide the relationship between the patient and themselves. If that family member is a son or daughter, their date of birth needs to be given.
The employee should then describe the care being provided to their family member and the estimated amount of leave that needs to be taken.
Certification of Health Care Provider for Family Member’s Serious Health Condition (WH-380-F) Section III: To be Completed by the Healthcare Provider
The third section of the WH-380-F form informs the patient’s healthcare provider that an employee is requesting leave under the FMLA to tend to their patient’s needs. Instructions for this section also tell the provider that vague terms such as “lifetime,” “unknown” or “indeterminate” should not be used to describe the patient’s condition and to use these words could lead to a denial of leave. The provider is also told that they should limit response to just the relevant medical condition.
First, the provider needs to give the healthcare organization’s name, business address, type of facility and contact information.
In Part A, the provider should say when the serious medical condition began and how long it might last. The provider also needs to say if the patient was admitted for an overnight hospital stay and if any medications were prescribed. The healthcare organization then has to describe the frequency of treatment visits, if the patient was referred elsewhere for treatment and if the condition is pregnancy.
In Part B, the provider needs to say if the patient will be incapacitated for any period of time. If so, the patient’s dates of incapacitation and any care during that time need to be given. The provider also needs to describe the care that will be provided.
In the next section of Part B, the provider needs to describe any follow-up treatments that the patient will require and a treatment schedule. The provider also needs to explain why any treatment is medically necessary and the hours per day and week that treatment will be given.
Finally, the provider needs to describe any periodic flare-ups that might occur after the initial treatment phase and how frequently these flare-ups might take place.