FMLA paperwork for a family member, completed and signed by a state-licensed provider
You fill out the intake. A state-licensed provider reviews your family member's condition and completes the WH-380-F, the New York PFL-4, or both.
Start My IntakeThe intake asks about your family member's condition and the care you give. Not about your own health.
Who does what
Youthe employee
- Fill out the intake and pay
Your family memberthe patient
- Gives authorization in the intake
- For NY PFL, signs the PFL-3, which stays with the provider
State-licensed provider
- Evaluates your family member
- Completes and signs the forms
Emailed to you as a PDF
How it works
- 1
Complete the intake
Add your details and your family member's: their condition and treatment, the care you provide, your absence pattern and dates, and which leave you're taking. Your family member's authorization is part of the intake. If you're using New York Paid Family Leave, it also asks about the PFL-3. If your employer gave you its own form, upload it here.
- 2
A state-licensed provider reviews it
A state-licensed provider evaluates your family member from the intake, usually within 24 hours after we have everything needed. A provider may follow up for more detail before deciding.
- 3
If the evaluation supports it, the certification arrives as a PDF
The completed certification comes by email. If the evaluation doesn't support it, you're refunded in full. What you do with it next depends on the leave, and the form sections below spell that out.
The FMLA form and the New York PFL forms
FMLA (Family and Medical Leave Act) and the WH-380-F
FMLA is a federal law. It covers leave to care for your spouse, son, daughter, or parent with a serious health condition. It applies to eligible employees of covered employers, and parents-in-law aren't covered under FMLA. The provider completes Section III of the WH-380-F, the health care provider's part.
Who counts as a parent, son, or daughter is defined in the FMLA regulations. Our WH-380-F guide walks through the definitions.
New York Paid Family Leave, the PFL-4 and the PFL-3
New York Paid Family Leave covers care for a spouse, domestic partner, child, stepchild, anyone you have legal custody of, parent, stepparent, parent-in-law, grandparent, grandchild, or sibling with a serious health condition, for employees the program covers. The provider completes the PFL-4, which certifies your family member's condition. Before that, your family member signs the PFL-3, a release that stays with the provider.
The PFL-1 is a different form. You and your employer fill that one out.
One case can involve both. If you're taking FMLA leave and New York Paid Family Leave for the same care, select both in the intake.
One flat fee
$49
$49 covers one leave case: the clinical review, the forms that case needs, and any follow-up your employer or leave administrator asks for afterward.
Completing our intake form starts the review; it does not guarantee a signature, and if the review does not support your request you are refunded in full.
The intake is a short online questionnaire, usually with no appointment, and the completed form comes back by email, usually within 24 hours after we have everything needed. A provider may follow up for more detail before deciding.
Start My IntakeSecure online intake. Your family member's information is reviewed by Certicare and is not sent to your employer or its insurance carrier without authorization.
Who fills out the form, and who is the patient?
You fill out the intake, as the employee taking leave. Your family member is the patient. A state-licensed provider reviews their condition and treatment, and their authorization is part of the intake. If your family member can't give it, a parent, legal guardian or authorized representative gives it for them.
The intake asks about the care you give and the dates you'll miss. It doesn't ask about your own health. New York Paid Family Leave doesn't cover an employee's own illness, and this page is about caring for someone else.
Which form do I need: WH-380-F, PFL-4, or both?
Go by the leave you're requesting. FMLA leave uses the WH-380-F. New York Paid Family Leave uses the PFL-4.
If you're taking both for the same care, both forms belong to one case. If you aren't sure which leave you're taking, ask your employer or its leave administrator which forms it wants before you start.
What if my family member can't sign the PFL-3?
An authorized representative can sign it. That person has to attach a copy of the legal documentation that lets them sign, unless they're a parent signing for a minor child.
Certicare needs the signed PFL-3 before completing the PFL-4. We keep it on file and never send it to the insurance carrier. Leave it out of the package you send the carrier, too.
Can I take family care leave a day at a time?
For New York Paid Family Leave, yes. It can be taken intermittently, in full-day increments.
FMLA leave can also be taken in separate blocks of time when medically necessary.
The intake asks for your absence pattern and dates either way.
What do I send if my employer gave me its own form?
Send us that form. Upload it in the intake, or email it to hello@certicare.org. Where the evaluation supports it, a state-licensed provider completes it along with the WH-380-F or PFL-4 your leave needs.
For New York Paid Family Leave, you send the package yourself. The PFL-1, the PFL-4, and any documentation go to your employer's insurance carrier within 30 days after your leave starts. That's your responsibility, not your employer's, and Certicare doesn't submit it for you.
Founded by a nurse practitioner who cares about workers
Certicare was founded by Rebecca Martel, APRN, FNP-BC, a family nurse practitioner board certified in family health and licensed in New York State. She started Certicare out of a commitment to workers' rights and a belief that getting the medical documentation you need shouldn't be complicated.