[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-305799-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-305799-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","paid-leave-certification-forms-june-2020-v2","Paid Leave Certification Forms - June 2020 v2","","Instructions and eligibility guidance for submitting Paid Family and Medical Leave certification forms. Covers which form to use for your own serious health condition, family leave to care for a seriously ill family member, and parental bonding leave after a child’s birth, including required proof such as a birth certificate or hospital documentation. Explains submission methods via a Paid Leave account or fax, strict rules against emailing certifications, authorization for designated representatives, and healthcare provider signing qualifications under RCW 50A.05.010 and WAC 192-500-090.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/paid-leave-certification-forms-june-2020-v2/305799/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/paid-leave-certification-forms-june-2020-v2/305799.png","ImageObject",442,249,{"name":42,"@type":43},"Miles","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-16","2026-09-19",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",9,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Which certification forms are required for medical leave due to your own serious health condition?","Question",{"text":63,"@type":64},"Use the Certification of Serious Health Condition Form (pages 1 and 2) or the US Department of Labor’s FMLA Certification of Health Care Provider for an employee’s serious health condition. It must verify your serious health condition, including pregnancy and childbirth-related leave.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How do I submit my completed forms?",{"text":68,"@type":64},"Upload completed forms through your Paid Leave account, include them with your application, or fax them to 833-535-2273. Do not submit certification forms via email; emailed documents are not accepted.",{"name":70,"@type":61,"acceptedAnswer":71},"Can someone else complete and sign the forms on my behalf?",{"text":72,"@type":64},"You may authorize a designated authorized representative to act for Paid Family and Medical Leave benefits by completing a Designated Authorized Representative form. Your representative can sign page 1 of the Certification for Serious Health Condition, but cannot sign for a healthcare provider when a healthcare provider’s signature is required.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},305799,1790497032,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":136,"language":137,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":12,"update_tm":141,"read_time":26},13056703019404,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","Which form do I need?  \nMedical leave due to your own serious health condition  \nCertification of Serious Health Condition Form (pages 1 and 2) or the US Department of Labor’s FMLA Certification of Health Care Provider for Employee’s Serious Health Condition Form to verify your own serious health condition, including medical leave related to pregnancy and giving birth.  \nFamily leave to take care of a family member with a serious health condition  \nCertification of Serious Health Condition Form (pages 1 and 2) or the US Department of Labor’s FMLA Certification of Health Care Provider for Family Member’s Serious Health Condition Form to verify your family member’s serious health condition.  \nParents taking family (bonding) leave following he birth of a child  \nCertification of Birth Form (last page), or a copy of your child’s birth certificate, or a copy of documentation from the hospital showing your child’s date of birth.  \nOther types of leave  \nDo not use this form for military exigency leave or for bonding leave when a child is placed in your home for adoption, foster care, or other approved placement types. Visit [PaidLeave.wa.gov](PaidLeave.wa.gov) for information and required forms for these types of leave.  \nHow do I submit my forms?  \nUpload completed forms through your Paid Leave account, include them with your application, or fax to 833-535-2273. You do not need to set up your Paid Leave account before your healthcare provider completes your forms.  \nDo not submit any certification forms via email. Emailed documents will not be accepted. Instructions for how to upload documents are on our website at [paidleave.wa.gov/technical-support](paidleave.wa.gov/technical-support).  \nCan someone else complete my forms for me?  \nYou may authorize another individual to act on your behalf for the purposes of Paid Family and Medical Leave benefits by having them complete a Designated Authorized Representative form. Contact us at 833- 717-2273 to request a copy of the Designated Authorized Representative form.  \nYour authorized representative can sign page 1 of the Certification for Serious Health Condition on your behalf. Your authorized representative cannot sign for a healthcare provider when completing any documentation requiring a healthcare provider’s signature.  \nQuestions?  \nIf you have any questions, please contact us at 833-717-2273 or [paidleave@esd.wa.gov](paidleave@esd.wa.gov).  \nWhat kinds of healthcare providers can sign these forms?  \nHealthcare providers who are authorized to sign this form are defined in RCW 50A.05.010 and WAC 192- 500-090. Generally,“healthcare provider” means:  \n• A physician or an osteopathic physician who is licensed to practice medicine or surgery, as appropriate, by the state in which the physician practices;  \n• Nurse practitioners, nurse-midwives, midwives, clinical social workers, physician assistants,  \npodiatrists, dentists, clinical psychologists, optometrists and physical therapists licensed to practice under state law and who are performing within the scope of their practice as defined under state law by the state in which they practice;  \n• A healthcare 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 performing within the scope of the healthcare provider's practice as defined under such law; or  \n• Other providers permitted to certify the existence of a serious health condition under the federal FMLA.  \nCertification of Serious Health Condition Form – Pages 1 & 2  \nWho should use this form?  \nThe information on the Certification of Serious Health Condition Form is required when applying for:  \n• Medical leave due to your own serious health condition.  \n• Medical leave due to your own pregnancy/child’s birth.  \n• Family leave to take care of a family member with a serious health condition.  \nWe cannot approve your application for these types of medical leave or family ","cbCaire7Fep38PyQ","https://ap.wps.com/l/cbCaire7Fep38PyQ","pdf",315086,6,"English","# Which form do I need?\n## Medical leave for your own serious health condition\n## Family leave for a family member’s serious health condition\n## Parents taking family (bonding) leave after a child’s birth\n## Other types of leave","[{\"question\":\"Which certification forms are required for medical leave due to your own serious health condition?\",\"answer\":\"Use the Certification of Serious Health Condition Form (pages 1 and 2) or the US Department of Labor’s FMLA Certification of Health Care Provider for an employee’s serious health condition. It must verify your serious health condition, including pregnancy and childbirth-related leave.\"},{\"question\":\"How do I submit my completed forms?\",\"answer\":\"Upload completed forms through your Paid Leave account, include them with your application, or fax them to 833-535-2273. Do not submit certification forms via email; emailed documents are not accepted.\"},{\"question\":\"Can someone else complete and sign the forms on my behalf?\",\"answer\":\"You may authorize a designated authorized representative to act for Paid Family and Medical Leave benefits by completing a Designated Authorized Representative form. Your representative can sign page 1 of the Certification for Serious Health Condition, but cannot sign for a healthcare provider when a healthcare provider’s signature is required.\"}]","Paid Leave Certification Forms - June 2020 v2 | PDF",1789828384]