D.C. Office of Paid Family Leave uses this form to determine patient's or caregiving family member's eligibility and duration of financial benefits.

Fill out this form when patient:

• is unable to work for health reasons OR

• needs time off work for treatment OR

• has family member taking time off work to provide care

To complete form, provider must document:

• Patient’s diagnosis or symptoms

• Primary and secondary ICD-10 codes

• Date health condition was diagnosed

  • Acute conditions: date of accident or illness onset

  • Chronic conditions: date of initial diagnosis or recent flare up

  • Pregnancy: last menstrual period or first prenatal visit

• Information about patient’s health condition

  • At least one box must be checked to receive benefits

• Amount and frequency of leave needed

  • This impacts the length of benefits

• For family caregiving benefits, type of care patient needs

Medical Certification Form requires provider signature.

Patients cannot receive benefits until their application is complete. Please complete the Medical Certification Form as soon as possible to maximize benefits for your patients.