FMLA WH 380 E Form Instructions (Certification of Health Care Provider for Employee’s Serious Health Condition)

When an employee requests an unpaid leave of absence under the FMLA for their own serious medical condition, it is required for the employee to submit the Certification of Health Care Provider for Employee’s Serious Health Condition form or an equivalent form. The employee is allowed 15 calendar days to submit the WH 380 E form to their employer.

Once the employer receives a completed certification the employer cannot ask for another certification. However if the employer doubts the validity of the information on the certification, the company or organization can pay for a second Certification of Health Care Provider of Employee’s Serious Health Condition form to be completed by another healthcare provider not employed by the company. If the initial and second certifications are in disagreement, then the company can pay for a third and binding medical opinion from a mutually-agreed-upon provider.

The Certification of Health Care Provider of Employee’s Serious Health Condition form is just one of many FMLA forms that needs to be completed. As stated above, the employee has 15 calendar days to have the finished WH 380 E form returned. If the certification is complete, then the employee will be approved their FMLA leave as outlined by the parameters in the certification. However, if the WH 380 E form is returned incomplete or the employer has reason to doubt its validity, then the process may be repeated or the employee may be denied their FMLA leave.

The US Department of Labor provides official FMLA forms for employers and employees to complete, including the Certification of Health Care Provider of Employee’s Serious Health Condition form, also called form WH 380 E. Employers covered under the law should have these FMLA forms on hand, however a substitute form with the same information can be used instead.

WH380E Certification of Health Care Provider for Employee’s Serious Health Condition
Section I: For Completion by the Employer

Instructions: Section I is to be completed by the employer before giving the WH 380 E form to the employee. It is not required to use the official WH 380 E form, however if a substitute form is used it must not request for additional information beyond those asked for in the WH 380 E. This form along with other information pertaining to the employee’s FMLA leave must be stored separately from other personnel records.

Fill out the basic information of the employer, including the name of the employer and contact person responsible for handling the various FMLA forms.
Thoroughly fill out the job title, work schedule, and basic job duties, so that the health care provider knows what the employee is able or unable to do at work with their given condition.

WH380E Certification of Health Care Provider for Employee’s Serious Health Condition
Section II: For Completion by the Employee

Instructions: Section II of the WH 380 E form is to be filled out by the employee. The employee must provide a “timely, complete, and sufficient medical certification” in order for their leave request to be properly processed. The employee has at least 15 calendar days to furnish the completed certification form, if they do not provide a completed certification their FMLA may be denied.

Write your first, middle, and last name to clearly identify the certification.

WH380E Certification of Health Care Provider for Employee’s Serious Health Condition
Section III: For Completion by the Health Care Provider

Instructions: Section III of the WH 380 E form is for the employee’s health care provider to complete. This section is to be filled out with the provider’s best estimate of the patient’s medical condition based off of their “medical knowledge, experience, and examination of the patient.” It is crucial for the provider to be specific in order to give the employee what they need. The provider must sign the last page of the WH 380 E form for the certification to be deemed complete.

Fill out the Provider’s name and address.
Fill out either the type of practice or specialization.
Fill out the phone number and fax number.

WH380E Certification of Health Care Provider for Employee’s Serious Health Condition
Section III: For Completion by the Health Care Provider

Part A: Medical Facts

Fill out when the patient’s relevant condition started
Fill out the length of time the patient will have the condition
Specify if the condition required any hospitalizations, treatments, prescription medications, and/or referral to other healthcare providers
Indicate if the condition is a pregnancy
Assess the condition as it relates to the job description provided by the employer in Section I of the WH 380 E form.
Describe any other medical facts.

WH380E Certification of Health Care Provider for Employee’s Serious Health Condition
Section III: For Completion by the Health Care Provider

Part B: Amount of Leave Needed

If the employee needs continuous time off, fill out the amount of time the employee will be incapacitated
If the employee needs a reduced work schedule, fill out the amount of follow-up treatments necessary, and how often these treatments will take place.
If the employee needs intermittent time off, fill out the estimated frequency and duration parameters for episodic flare-ups and/or appointments.
Fill out any additional information if necessary
Sign the certification and provide the date the certification was filled out

Click Here: To View and Download Form WH380E


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