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Certification of Health Care Provider for Employees Serious Health Condition under the Family and Medical Leave Act. S. Department of Labor Wage and Hour Division DO NOT SEND COMPLETED FORM TO THE
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Who needs a Form WH-380-E?

Certification of Health Care Provider for Employee’s Serious Health Condition, Form WH-380-E, should be completed in case when an employer requires an employee seeking Family and Medical Leave Act protections because of a need for a leave due to a serious health condition to provide a medical certification issued by the employee’s health care provider.

This form should be completed by both, the employer and the employee. Also, section 3, the main part of this form should be completed by the employee’s health care provider.

What is Form WH-380-E for?

The employee’s health care provider should provide all applicable facts answering all parts of the form. Based on information provided, an employer can get an idea about the illness of the employee and the time it takes for treatment. Also, this form is used to determine whether the employee actually is subject for FMLA protection.

Is Form WH-380-E accompanied by other forms?

Additional documents are not required in order to complete WH-380-E.

When is Form WH-380-E due?

This form may be requested as needed. Its filling is not regulated by a specific deadline.

How do I fill out Form WH-380-E?

Each of the three parts of this form has its own instructions to be read before filling out.

The following information should be provided in order to complete the form:

  • Employer’s personal information;
  • Employee’s personal information and job title;
  • Provider’s personal and business information;
  • Medical facts Amount of leave needed;
  • Any additional information.

After completion, the signature of the provider should be put.

Where do I send Form WH-380-E?

If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. Do not send the completed form to the Department of Labor; Return it to the patient.

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Our HR hotline Christi's countless questions throughout the year regarding which medical professionals can fill out FMLA forms for employees which is what we will be discussing in a few moments but first a little background regarding the FMLA process in order to be placed on a Family Medical Leave a health care provider must complete a certification form in order to ensure the validity of the serious health condition the FMLA regulations specifically define the term health care provider as a doctor of medicine or Osteopathy who is authorized to practice medicine or any other person determined by the Secretary of Labor to be capable of providing health care services the other persons capable of providing health care services must be authorized to practice in their state and authorized to diagnose and treat physical or mental health conditions examples include providers such as podiatrists dentists clinical psychologists optometrists chiropractors nurse practitioners midwives clinical social workers' physician assistants and certain Christian Science practitioners, although this is not an exhaustive list it is important to remember that non-traditional providers may still meet the definition outlined by FMLA regulations if you are questioning a medical professionals' authorization to flout the FMLA form it is always best to check the published FMLA regulations or members of the management Association may always contact the HR hotline for assistance you


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