Paid Family &
Medical Leave
MASSACHUSETTS

1

Certification of Your Serious Health Condition
You are required to notify your employer before submitting an application. Once you have notified your employer, the
Department of Family and Medical Leave (DFML) will review your application to determine your eligibility for benefits.
Both the employee who is applying for leave and a health care provider must complete a portion of this form. This
form will be shared with DFML, your employer, employer affiliates, and state partners.

This form is required for...

This form is not required for Family Leave to...

      Medical leave due to your
own serious health condition
or conditions due to pregnancy or
post-birth recovery that prevent
you from working, as certified by
a health care provider.

      Care for a family
member with a serious
health condition including
a family member with a
serious health condition
related to military service.

      Bond with a child
within 12 months after
birth, adoption, or
foster care placement.

      Manage affairs
for a family member
who is an active
service member.

How to use this form

Employee

Health Care Provider (HCP)

1.  Complete Section 1 to tell us about your reason

1.  Review Page 2 for definitions of key terms.

for taking leave.

2.  Print your name on Pages 4-6.

2.  Complete Sections 2-4 to certify the patient’s

serious health condition.

3.  Give all 6 pages of the form to the health care

3.  Sign and date form on Page 6 to attest to the

provider who is treating you. The health care
provider will complete Sections 2-4 and return the
form to you. Benefits will be delayed or denied
without certification from a health care provider.

information provided.

4.  Return the entire form to the patient whose

information is in Section 1.

4.  Apply for leave at Mass.gov/paidleave-apply.
When you apply you will need this entire
completed form. Some of the questions in the
application will refer to the form.

5.  Upload the entire completed form to your paid
leave account at Mass.gov/paidleave-apply. You
may need to take a photo of your form or scan
it to upload it. If you don’t have a way to upload
the form, fax it to us at (617)-855-6180, or call our
Contact Center at (833)-344-7365.

Questions?Contact us at (833) 344-PFML (7365) or find us online at Mass.gov/DFML.PFML-FORM-Cert-SHC V. 7.0, March 2025PageDefinitions of
key terms

A

Employee

Health Care Provider

Refer to this page as you fill out the form.

2

Definition of a serious health condition

A serious health condition could include an illness, injury,
impairment or physical or mental condition that involves at
least one of the following two conditions:

1.  At least one night of inpatient care in a hospital, hospice or

residential medical facility

2.  Continuing treatment by a health care provider

Inpatient care
An overnight stay in a hospital, hospice, or residential medical care
facility, including any period of incapacity, or any subsequent treatment
in connection with such inpatient care.

Continuing treatment
Treatment for a condition that fits any of the following descriptions:

A.  Any incapacity to work for more than three consecutive full

calendar days that also requires medical visits. Your patient’s
first visit must be within seven days of the start of incapacity.
Telehealth appointments are also included. These medical visits
must meet one of the following two patterns:

•

•

Two or more visits within 30 days of a patient’s incapacity to
work (unless it is impossible to book two appointments in this
time frame).

One such visit—excluding a routine physical, eye or dental
exam—plus a regimen of care or medication under the
provider’s supervision or prescription, e.g., outpatient surgery
or strep throat.

B.  Any incapacity due to pregnancy or prenatal care.

C.  Any incapacity due to a chronic condition, which is a condition

that:

•

•

Requires periodic medical visits,

Continues over an extended period of time, and

•  May cause episodic periods of incapacity that require leave,

e.g., asthma or migraine headaches.

D.  Any incapacity due to a permanent or long-term condition that
may not respond to treatment, e.g., Alzheimer’s disease or
terminal stages of cancer.

E.  Any absence to receive multiple treatments, plus any recovery

time, for either of the following:

•

•

Restorative surgery after an accident or injury, e.g., joint
replacements or reconstruction.

A condition that would lead to more than three consecutive
days of incapacity if the patient did not receive treatment,
e.g., chemotherapy treatments.

Incapacity
An inability to perform the functions of one’s job owing to the serious
health condition. For unemployed applicants, it means an inability to
perform the functions of their most recent position or other suitable
employment.

Definition of a health care provider

Health Care Provider:
An individual licensed by the state, commonwealth, or territory
in which the individual practices medicine, surgery, dentistry,
chiropractic, podiatry, midwifery or osteopathy, and including
the following:

A.  Podiatrists, dentists, clinical psychologists, optometrists,

and chiropractors (limited to treatment consisting of manual
manipulation of the spine to correct a subluxation as
demonstrated by X-ray to exist) authorized to practice in a state
and within the scope of their practice as defined under the law of
that state, commonwealth, or territory;

B.  Nurse practitioners, nurse-midwives, clinical social workers and
physician assistants who are authorized to practice under State
law and who are within the scope of their practice as defined
under the law of that state, commonwealth or territory;

C.  Christian Science Practitioners listed with the First Church of

Christ, Scientist in Boston, Massachusetts;

D.  A health care provider listed above who practices in a country
other than the United States, who is authorized to practice in
accordance with the law of that country, and who is within the
scope of practice as defined under such law.

Questions?Contact us at (833) 344-PFML (7365) or find us online at Mass.gov/DFML.PFML-FORM-Cert-SHC V. 7.0, March 2025PagePaid Medical Leave | Certification of Your Serious Health Condition
Employee Applying for
Paid Medical Leave

Instructions - Complete this section with your own information.
The DFML will use Section 1 to match this certification to the rest of
your application for paid leave.

1

3

1

Your name:

First:

Last:

2

(If different) Your name as it appears on official documents like a driver’s license or W2:

First:

Middle:

Last:

3

Phone #:

_ _ _

-

_ _ _

-

_ _ _ _

4

Date of birth:

_ _  / _ _  / _ _ _ _
m       m                     d         d                      y         y         y         y

5

Last 4 digits of your Social Security Number or Individual Taxpayer ID Number (ITIN):

_ _ _ _

6

7

Occupation:

Optional: NTN - _ _ _ _ _ _ _  - ABS - 01

Including the application claim number may help your application be processed more efficiently. If you plan on having your healthcare
provider submit this form on your behalf, please ensure that you have started your application at paidleave.mass.gov and received your
claim number.

Employee

Write your name at the top of the remaining pages.
Afterwards, give this form to your health care provider to complete Sections 2–4.

Questions?Contact us at (833) 344-PFML (7365) or find us online at Mass.gov/DFML.PFML-FORM-Cert-SHC V. 7.0, March 2025PagePaid Medical Leave | Certification of Your Serious Health Condition4

Employee

Your Name:

Health Care Provider

Health Care Provider Certification of a Serious Health Condition

2

8

Patient’s Serious
Health Condition

Instructions - This form should be filled out by the employee’s health care
provider. For the employee to qualify for paid leave, the patient must have a
serious health condition. Answer all questions fully and completely.

Which of the following apply to the patient’s serious health condition? Check all that apply; this includes mental health.

Requires, or did require
inpatient care.

Has incapacitated or will incapacitate
the patient for more than three
consecutive full calendar days, AND
(pick one)

Requires two or more medical
visits within 30 days.

OR

Requires one medical visit,
plus a regimen of care.

Is chronic, requires treatments at
least twice a year, and may require
periodic absences.

Is long-term and requires ongoing
medical supervision, with or without
active treatment.

Requires multiple treatments and
would lead to a period of incapacity
without treatment.

None of the above.

If none apply, the patient is not
eligible for PFML

9

Provide appropriate medical facts about the patient’s serious health condition (e.g., symptoms, prescriptions, referrals for
evaluation or treatment):

10

State at least one essential job function the patient is unable to perform due to their serious health condition (e.g.,
specific tasks like sitting at a computer, performing manual labor, making decisions, or the ability to work at all)

11

12

Is this serious health condition a job-related injury?

Yes              No

Is the patient’s serious health condition related to pregnancy or recovery
from childbirth?

Yes              No

If yes, how much time will the patient need?

•

•

The patient will need approximately                weeks for pregnancy or
prenatal care

The patient will need approximately                weeks for recovery from
childbirth or postnatal care.

13

When is the expected delivery date: _ _  / _ _  / _ _ _ _
m       m                     d         d                      y         y         y         y

Medical leave for pregnancy, prenatal care, or
recovery from childbirth must meet the definition of
a serious health condition.

Taking Medical Leave does not impact a patient’s
ability to take Family Leave to bond with their child,
provided that the number of weeks taken for leave
does not exceed the 26-week maximum in a benefit
year. There is no form needed to take family
leave to bond with a child- just proof of birth.
Learn more.

Questions?Contact us at (833) 344-PFML (7365) or find us online at Mass.gov/DFML.PFML-FORM-Cert-SHC V. 7.0, March 2025PagePaid Medical Leave | Certification of Your Serious Health Condition5

Employee

Your Name:

Health Care Provider

3

14

Estimate Leave
Details

Instructions - The following questions are about the frequency or duration of a
condition. Check all that apply to the patient’s condition but you must provide your
best estimate of the start and end dates and the duration based on your medical
knowledge, experience, and examination of the patient.

Continuous Leave: Due to the condition, the patient is/will be incapacitated for a continuous period of
time (completely unable to work for consecutive, uninterrupted days).

Provide your best estimate of the beginning date ___________________ (mm/dd/yyyy) and end date ________________ (mm/dd/
yyyy) for the period of incapacity.

Do not use terms like “unknown” or “TBD” as it may result in delays and revisions to the form.

15

Reduced Leave: Due to the condition, it is medically necessary for the patient to work a reduced but
consistent schedule.

Provide your best estimate of hours that the patient should take off per week during the reduced leave schedule. From

____________________ (mm/dd/yyyy) to __________________ (mm/dd/yyyy) the patient is not able to work: (e.g., 5 hours/day, up to

25 hours a week) __________________________________________________________________________________.

Do not use terms like “unknown” or “TBD” as it may result in delays and revisions to the form.

16

Intermittent Leave: Due to the condition, it is medically necessary for the patient to be absent from work
on an intermittent basis (multiple episodes of time off, which may be irregular or unexpected). Provide your
best estimate of how often (frequency) and how long (duration) the episodes of incapacity will likely last.

From roughly ________________ (mm/dd/yyyy) to __________________ (mm/dd/yyyy) (over the next 6 months), episodes of

incapacity are estimated to occur ____________________ times per (    day/     week/     month) and are likely to last approximately

___________________ (     hours/     days) per episode.

Do not use terms like “unknown” or “TBD” as it may result in delays and revisions to the form.

Questions?Contact us at (833) 344-PFML (7365) or find us online at Mass.gov/DFML.PFML-FORM-Cert-SHC V. 7.0, March 2025PagePaid Medical Leave | Certification of Your Serious Health Condition6

Employee

Your Name:

Health Care Provider

Provider’s Certification
& Information

Instructions - Sign and date to agree to this declaration. Provide the
relevant licensing and contact information about your practice or
business. Before returning the form, review Pages 3-6.

4

I certify that the information provided in this form is true and correct, that I have examined the patient
and answered the questions accurately and to the best of my ability, and that I am a health care provider
authorized to certify their condition.

See page 2 for the definition of a health care provider.

Date:

_ _  / _ _  / _ _ _ _
m       m                     d         d                      y         y         y         y

17

Signature:

18

Printed name and title:

Name:

Title:

19

Certificate/license to practice number:

State/Country:

Note       The form will not be accepted unless a license number is provided.

20

21

Area of practice or medical specialty:

Name of your practice or business:

22

Address:

23

Office phone #:

_ _ _

-

_ _ _

-

_ _ _ _

24

Office fax #:

_ _ _ -

_ _ _

-

_ _ _ _ (optional)

Health Care Provider

When you have completed and signed the certification, return it to your patient. The
patient will submit this information for review by the DFML and their employer.

Questions?Contact us at (833) 344-PFML (7365) or find us online at Mass.gov/DFML.PFML-FORM-Cert-SHC V. 7.0, March 2025PagePaid Medical Leave | Certification of Your Serious Health Condition