This article is here to provide a standardized process for assisting patients who request medical certification paperwork for Family and Medical Leave Act (FMLA) purposes, while ensuring compliance with federal law, patient confidentiality, and besa Health policies.



📚Resources Needed


🚀 Tips & Tricks

  • All the information you will need to fill out the form will be in the Patient encounter. 
     
  • In some cases, you may need to check previous Patient encounters in order to get all the data needed to fill out the form. 
     
  • You never fill out section I. That is for the Employer or the Employee to complete. 
     
  • FMLA is a federal program, but California also has CFRA (California Family Rights Act) with similar paperwork. Be prepared that patients may bring CFRA forms as well.
     
  • Protect patient confidentiality at all times. Do not release medical information beyond what is required for certification.

     

📘 Instructions

Make sure not to forget one of these steps. 
 

  1. When a patient requests FMLA paperwork, staff should:
     
  • Politely explain that the employer is responsible for providing the official FMLA paperwork.
  • Ask the patient: “Did your HR department give you their FMLA form?”
     

2. If the patient has the employer’s FMLA form:

  • Make a copy for the chart.

  • Use the information in the Patient encounter to complete the form or give the form to the treating provider to complete.

     

    3. If the patient does not have a form:
     

    • Provide the patient with the federal Department of Labor form WH-380-E (Employee’s Serious Health Condition).
    • Inform the patient: “Your employer may require their specific version. If so, please bring that back to us for completion.”
    • Do not complete section l. 
       

4. Completion of Forms

  • The treating provider or care manager completes the form based on medical evaluation.
  • Only functional limitations, work restrictions, and duration of leave should be included — not the specific diagnosis, unless the patient authorizes it.
  • Sign and date the form, and it is scanned into the patient’s chart.
     

5. Returning Forms

  • Completed forms must be returned to the patient only, never directly to the employer (unless patient provides written authorization).
  • Staff should remind patients:
    “Please submit this directly to your employer’s HR or Leave Department.”
     

6. Follow Up 

  • If HR requests clarification, they must submit it in writing.
  • The provider may issue an addendum or clarification letter if medically appropriate.
  • All communication must be documented in the patient’s chart.

     

7. If you have any questions or need more information, please contact the office manager.