Massachusetts Paid Family and Medical Leave (PFML) - Certification of Your Family Member's Serious Health Condition Instructions

Sep 19, 2026

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Massachusetts Paid Family and Medical Leave (PFML) provides instructions for completing the Certification of Your Family Member's Serious Health Condition form. The employee must notify the employer before applying, then coordinate sections of the form between the employee and a health care provider. The guide explains which situations qualify for leave, what is excluded for different categories of leave, and how benefits may be delayed or denied without provider certification. It also defines “serious health condition,” including inpatient care and continuing treatment patterns.

LanguageEnglish

CategoryLetters

FormatPDF

Pages14

Reading Time5 min

AccessFree to download

How to use this form

Employee

Health Care Provider (HCP)

Definition of a serious health condition

Inpatient care

Continuing treatment

Definition of incapacity

Definition of a health care provider

Equitable Financial Life Insurance Company of America For Assistance Call (866) 274-9887 Send completed forms to: Equitable, EB Claims 8501 IBM Dr, Suite 150-C Charlotte, NC 28262 Fax Number: (315) 477-2499 [ebclaims@equitable.com](ebclaims@equitable.com) Massachusetts Paid Family and Medical Leave (PFML) Certification of Your Family Member's Serious Health Condition Instructions You are required to notify your employer before submitting an application. Once you have notified your employer, Equitable Financial Life Insurance Company of America (Equitable) 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 Equitable, your employer, employer affiliates, and state partners. This form is required for... Leave to care for a family member with a serious health condition including a family member with a serious health condition related to military service. This form is not required for Family Leave to... Medical leave due to your own serious health or conditions due to pregnancy or post-birth recovery that prevent you from working, as certified by a health care provider. Bond with a child within 12 months after birth, adoption, or foster careplacement. Manage affairs for a family member who is an active service member. How to use this form • Employee 1. Complete Section 1 and 2 and Affidavit of Qualifying Family Relationship to tell us about yourself and the family member you need to care for. 2. Write your name at the top of Pages 5-7. 3. Give all pages of the form to the health care provider who is treating your family member. 4. The health care provider should complete Sections 3-5 and return the form to you. Benefits will be delayed or denied without certification from a healthcare provider. 5. Provide the Employer Coverage Certification to your employer to complete. 6. Send the entire completed form to Equitable, EB Claims 8501 IBM Dr, Suite 150-C Charlotte, NC 28262 Fax Number: (315) 477-2499 [ebclaims@equitable.com](ebclaims@equitable.com) Call our Contact Center at (866)-274-9887 with any questions. + Health Care Provider (HCP) 1. Review Page 2 for definitions of key terms. 2. Complete Sections 3-5 to certify the patient’s serious health condition. 3. Make sure the patient has provided authorization to share medical information with the employee. 4. Sign and return the entire form to the employee whose information is in Section 1. Continued on next page Questions? Contact us at 866-274-9887 or write us at [ebclaims@equitable.com](ebclaims@equitable.com) Equitable is the brand name of the retirement and protection subsidiaries of Equitable Holdings, Inc., including Equitable Financial Life Insurance Company (NY, NY); Equitable Financial Life Insurance Company of America, an AZ stock company with an administrative office located in Charlotte, NC; and Equitable Distributors, LLC. The obligations of Equitable Financial Life Insurance Company and Equitable Financial Life Insurance Company of America are backed solely by their claims-paying abilities. EBMAPFML-COFMINSTR (9/1/2025) Page 1 of 2 Massachusetts Paid Family and Medical Leave (PFML) Certification of Your Family Member's Serious Health Condition Instructions |
• Employee + Health Care Provider | Refer to this page as you fill out the form. | | --- | --- | | 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

FAQs

When must the employee notify the employer, and what happens after notification?

The employee is required to notify the employer before submitting an application. After notification, Equitable reviews the application to determine eligibility for benefits.

Which leave situations require this PFML certification form?

This form is required to request leave to care for a family member with a serious health condition, including conditions related to military service. It is not required for certain medical leave for the applicant’s own serious health condition, pregnancy recovery, child bonding within 12 months, or managing affairs for an active service member.

What qualifies as a “serious health condition” under the form’s definition?

A serious health condition can include illness, injury, impairment, or physical or mental conditions involving inpatient care (including an overnight stay) or continuing treatment by a health care provider. Continuing treatment includes specific patterns such as multiple medical visits within set timeframes, treatment regimens under supervision or prescription, pregnancy or prenatal care, chronic conditions with periodic visits, permanent or long-term conditions, and multiple treatments with recovery time.

Sep 19, 2026

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