Medical Certification - Paid Family & Medical Leave - Serious Health Condition

Sep 19, 2026

Medical Certification forms for Paid Family and Medical Leave define what qualifies as a serious health condition under RCW 50A.05.010. The guide explains when to use the form for a patient’s own serious health condition, pregnancy, or care for a family member, and provides steps for patients to complete Section 1, while providers complete Section 2 and sign. It also outlines required return timing, instructions about fees, and examples of inpatient care, continuing treatment, chronic, pregnancy, permanent or long-term conditions.

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CategoryForms

FormatPDF

Pages3

Reading Time1 min

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Medical Certification

Steps for completing the form

Instructions for health care providers

What counts as a serious health condition

What to do when a form is received

Medical Certification Paid Family & Medical Leave STEP 1: Select the right form Use this form when you’re applying for paid medical leave for your own serious health condition. STEP 2: Fill out the form You complete required fields (*) in SECTION 1: Patient information. Your health care provider completes SECTION 2: Health care provider certification. Health care provider instructions are included in this packet. STEP 3: Upload your completed form Upload your completed form in your Paid Leave account or fax to 833-535-2273. Certificadomédico Permiso de cuidado pagado PASO 1: Seleccione el formulario correcto Use este formulario cuando solicite un permisomédico pagado para su propia condición de salud grave. PASO 2: Complete el formulario Usted completa los campos obligatorios (*) en la SECCIÓN 1: Información del paciente. Su proveedor de atención médica completa la SECCIÓN 2: Certificado del proveedor deatención médica. Las instrucciones para el proveedor de atención médica se incluyen en este paquete. PASO 3: Cargue su formulario completo Cargue su formulario completo en su cuentade Permiso de cuidado pagado o envíelo por fax al 833-535-2273. Instructions for Health Care Providers “Health care provider” is defined by law in RCW 50A.05.010 and WAC 192-500-090. Paid Leave medical certification forms are used to certify a serious health condition to qualify for Paid Family and Medical Leave. Your patient may be applying due to their own serious health condition, their pregnancy, or to care for a family member with a serious health condition. Our Certification of Birth form can be used for the first six weeks of medical leave to recover from giving birth and for family leave to bond with a new baby. What to do when you receive a form: Fill out Section 2. Within 7 calendar days of receipt, return the form to your patient (they will share it with us) . You cannot charge a fee for completing the form. SERIOUS HEALTH CONDITION A serious health condition is defined in RCW 50A.05.010. Generally, a serious health condition could include an illness, injury, impairment, or physical or mental condition that involves: • Inpatient care in a hospital, hospice, or residential medical care facility, including any period of incapacity; or • Continuing treatment by a health care provider including any of the following: • Incapacity: A period of incapacity of more than three consecutive days and subsequent treatment or period of incapacity relating to the same condition. Incapacity means an inability to work, attend school, or perform other regular daily activities because of a serious health condition, treatment of that condition or recovery from it, or subsequent treatment. • Pregnancy: Any period of incapacity due to pregnancy, or for prenatal care. • Chronic conditions: Any period of incapacity or treatment for such incapacity due to a chronic serious health condition. A chronic serious health condition is one which: » Requires periodic visits to a health care provider; » Continues over an extended period of time, including recurring episodes of a single underlying condition; and » May cause episodic rather than a continuing period of incapacity, including asthma, diabetes, and epilepsy. • Permanent/Long-term: A period of incapacity which is permanent or long-term due to a condition for which treatment may not be effective. The employee or family member must be under the continuing supervision of, but need not be receiving active treatment by, a health care provider, including: » Alzheimer’s, a severe stroke, or the terminal stages of a disease; or » Multiple treatments: Any period of absence to receive multiple treatments, including any period of recovery from the treatments. » Substance abuse may be a serious health condition if the treatment meets other requirements in this definition. FOR MORE INFORMATION: Visit [paidleave.wa.gov/healthcare-providers](paidleave.w

FAQs

When should a patient use this medical certification form?

Use the form when applying for paid medical leave for the patient’s own serious health condition. It can also support requests related to pregnancy or care for a family member with a serious health condition.

What are the patient and health care provider responsible for completing?

The patient completes required fields in SECTION 1 (Patient information). The authorized health care provider completes SECTION 2 (Health care provider certification), including required descriptions and dates, and signs where indicated.

What is considered a serious health condition under the guide?

A serious health condition may include inpatient care, continuing treatment by a health care provider, incapacity lasting more than three consecutive days, pregnancy-related incapacity or prenatal care, chronic conditions, permanent/long-term conditions, and absence for multiple treatments when requirements are met.

Sep 19, 2026

Upload by Bill Black