Administrative — FMLA Medical Certification Template

The FMLA Medical Certification Template guides healthcare providers through completing the required documentation for employees requesting Family and Medical Leave Act (FMLA) leave from their employers. The Family Medical Leave Act requires medical certification from healthcare providers to support employee requests for unpaid, job-protected leave for serious health conditions, care of family members, or qualifying military family events. This template follows the Department of Labor's WH-380-E (Certification of Healthcare Provider for Employee's Serious Health Condition) and WH-380-F (Certification for Family Member's Serious Health Condition) forms, systematically collecting all required information including patient demographics, diagnosis information (with sufficient detail without HIPAA violations), medical facts supporting need for leave, probable duration of condition, treatment plan and frequency, whether condition requires ongoing treatment, assessment of patient's inability to perform work functions, and whether intermittent or reduced schedule leave is medically necessary. The template ensures compliance with federal FMLA regulations, protects patient privacy while providing necessary information, supports employee rights to medical leave, and streamlines the certification process for busy providers. Ideal for family medicine, internal medicine, psychiatry, and all specialties that treat conditions warranting medical leave, this template prevents incomplete forms that delay employee leave approval and reduces provider time spent on administrative paperwork.