INSTRUCTIONS: WH380E FMLA Forms

When an employee requests an unpaid leave of absence under the FMLA for their own serious health 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. Certification of Health Care Provider of Employee’s Serious Health Condition form.

An employee might need to take off from work to care for their own medical condition only – the medical certification may be requested, along with the completion of a number of other FMLA forms. The employee is allowed 15 days to obtain proper validation from the appropriate healthcare provider.

If the employer does not consider the initial medical certification valid, 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 a different healthcare provider, so long as that provider is not employed by the company. If the initial and second certifications are in disagreement, then company can pay for a third and binding medical opinion from another mutually-agreed-upon provider.

The US Department of Labor does provide 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, but they can also be found at the DOL website.

The first section of the WH-380-E form simply asks for basic information from the employer, such as the name of the employer. The first section also asks for the job title of the employee requesting leave, their work schedule and their basic job duties. So that health care providers know what the employee is able or unable to do at work with their given condition it is required that the employer accurately fills out the job title, work schedule, and basic job duties.

The second section of the WH-380-E form is for the employee. It informs the employee that they must provide “a timely, complete, and sufficient medical certification” in order for their leave request to be properly processed. The employee is also told they have at least 15 calendar days to furnish the completed certification form.

The third section of the WH-380-E form is for the employee’s health care provider. This section tells the provider they will need to describe the frequency or seriousness of their patient’s medical condition. It also asks them for a good estimated period of a patient’s condition “based upon your medical knowledge, experience, and examination of the patient.”

Part ‘A’ of the WH-380-E form’s third section asks the provider to say when the patient’s relevant condition started, the length of time they have had it and if the condition required any hospitalizations. The section then asks for any treatments received, including prescription medications. The medical provider must also assess the condition as it relates to the job description provided by the employer in the first section of the WH-380-E form.

Part ‘B’ of the form asks the medical provider to determine the amount of leave the requesting employee might need to treat either their own medical condition. The form asks if the person with the condition is or will be incapacitated for any amount of time. The form also asks if any follow-up treatments are necessary, and if so how often these treatments will take place.

Finally, the sections ask the provider if there is a possibility of any ‘flare-ups’ associated with the condition that might prevent the employee from doing their job. It is critical that the health care provider specifies the frequency and duration parameters for episodic flare-ups and/or appointments.

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 days to have the finished WH-380-E form returned. If the employer deems the medical certification to be valid, then the application process is complete. However, if the employer disputes the certification; the process will have to be repeated.

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