New York’s PFL-4 form is the Health Care Provider Certification you file when you take Paid Family Leave to care for a family member with a serious health condition. You fill out the top section with your identifying information and your family member’s name and date of birth; your family member’s healthcare provider completes the medical certification below. The form then travels with Form PFL-1 (your leave request) and Form PFL-3 (a medical privacy release) to your employer’s insurance carrier, and the full package must arrive within 30 days of your leave start date.
Getting the provider’s portion back on time is the single biggest challenge in the process, so plan the paperwork around that bottleneck.
What the PFL-4 Does and Why It Travels With Two Other Forms
PFL-4 is the medical proof that your family member has a serious health condition requiring your care. The provider documents the diagnosis, when the condition started, how long care is expected to last, and how many days per week or month your family member needs you. Without this certification the insurance carrier has no medical basis to approve your leave, and the claim stalls or gets denied.
Two companion forms go with it. Form PFL-3 is the Release of Personal Health Information, a HIPAA authorization your family member signs so their provider can share medical details with the carrier. Form PFL-1 is your request for leave, with a section you complete and a section your employer completes. All three forms are submitted together as one package.
A quick boundary before you start: PFL covers care for a spouse or domestic partner, child or stepchild, parent, stepparent or parent-in-law, grandparent, grandchild, or sibling, and a serious health condition means an illness or injury involving inpatient care or continuing treatment by a healthcare provider. Routine ailments like a cold, flu, earache, or ordinary headache do not qualify. If your situation falls outside those lines, PFL-4 isn’t the form you need.
Filling Out the Employee Section
The top portion of PFL-4 is yours. Have this information in front of you before you start:
- Your full legal name (first, middle initial, last)
- Your date of birth
- Other last names you have worked under, if any
- Your Social Security number or Taxpayer Identification Number
- Your mailing address
- The care recipient’s full name (first, middle initial, last)
- The care recipient’s date of birth
Match your name and Social Security number to your employment records exactly. If you’ve changed your name since starting the job and haven’t updated your records, list both names. The care recipient’s name and date of birth need to match whatever the provider enters below. A mismatch here is a common reason the carrier pauses the file.
When your section is complete, make a copy for your records before handing the form over.
What the Healthcare Provider Fills In
The provider section is the medical heart of the form, and only your family member’s treating provider can complete it. You cannot fill in any of these fields yourself. The provider answers:
- Whether the patient requires care by this specific employee. A “no” answer ends the certification. The form defines “providing care” broadly: physical care, emotional support, visitation, help with treatment, transportation, arranging changes in care, assistance with daily living, and personal attendant services all count.
- The diagnosis, with an optional ICD-10 code
- The date the condition started
- The first date care from the employee is needed
- The expected date the patient will no longer require care
- The estimated frequency of care needed, in days per week or days per month
The provider also enters their own credentials: name, provider type (MD, DO, NP, PA, licensed psychologist, licensed social worker, and others), mailing address, phone, fax, email, state of license, specialty, and license number. They sign and date under a fraud warning.
Getting the Provider’s Section Back in Time
This is where most claims die. Providers are busy, and a form sitting in a to-do pile can burn through your 30-day filing window.
A few tactics help. Go with your family member to an appointment and ask the provider to complete the form during the visit. Tell the provider in plain terms that you have a hard 30-day deadline to submit the full package to your carrier. Fill out every field in the employee section before handing the form over; providers move faster when the rest of the paperwork is already done. If the office tells you it will take a week or more, ask whether a nurse practitioner or physician assistant on the care team can complete it sooner, since the form accepts those provider types.
The PFL-3 Signature People Get Wrong
Form PFL-3 is signed by your family member, the person receiving care, not by you. You cannot sign it on their behalf simply because you are the one taking leave. This trips up applicants constantly, especially when the family member is seriously ill and paperwork feels like the last priority.
If your family member cannot sign due to incapacity, a legally authorized representative such as someone holding healthcare power of attorney can sign in their place, but the legal authority documentation has to be included with the submission. Get the PFL-3 signature early. Your family member hands the signed PFL-3 to their provider to keep on file, and that authorization is what lets the provider complete PFL-4 and share information with the carrier.
Submitting the Complete Package
Once the three forms are ready, assemble them together:
- Form PFL-1, with Part A completed by you and Part B completed by your employer
- Form PFL-3, signed by your family member or their authorized representative
- Form PFL-4, with your section and the provider’s section both complete
Send the package directly to your employer’s insurance carrier. Do not send it to the Workers’ Compensation Board, and do not send it to your employer’s HR department, though you should notify your employer that you are taking leave. If you don’t know which carrier handles your employer’s PFL coverage, ask HR or check your pay stub, which may list the carrier.
The package must reach the carrier within 30 days after the first day of your leave. Miss that window and the carrier can deny the claim. If your employer fails to complete Part B of PFL-1 within three business days, your request cannot be treated as incomplete for that reason alone. Submit what you have and note that the employer section is pending.
Keep copies of every form you send. If something goes missing in transit or the carrier says it never arrived, your copies are the only proof you have.
What Happens After the Carrier Receives Your Forms
The insurance carrier has 18 calendar days from receiving a complete package to approve the claim and start paying benefits or to deny it. If anything is missing, a blank field on PFL-4, an unsigned PFL-3, the carrier pauses the review and the 18-day clock does not start until the gap is filled.
Approved benefits pay 67 percent of your average weekly wage, calculated from your last eight weeks of pay before the leave, capped at 67 percent of the New York Statewide Average Weekly Wage. For 2026 the maximum weekly benefit is $1,228.53. You can take up to 12 weeks of leave in any 52-week period. Your employer must keep your health insurance in place on the same terms as if you were still working, and you remain responsible for your share of the premium. Your job is protected, and your employer cannot retaliate against you for taking PFL.
If the Carrier Denies Your Claim
A denial comes with a written explanation and instructions for requesting arbitration. You have six months from the denial date to file for arbitration with National Arbitration and Mediation. There is a $25 filing fee, reimbursed if the arbitrator rules in your favor.
To file, complete Form PFL-ARBN and include a copy of the denial notice, your original PFL application and supporting documents, and any additional evidence. You can mail the package to National Arbitration and Mediation, 990 Stewart Avenue, 1st Floor, Garden City, NY 11530, Attn: PFL Arbitrations, or file online at www.nyspfla.com. Either way, send copies of your arbitration request and supporting documents to both the insurance carrier and your employer at the addresses listed on the denial notice.
If your leave already started before the denial came through, that time off is not treated as Paid Family Leave, and your employer decides how to classify the absence. The best protection against that outcome is getting PFL-4 and the rest of the package right the first time.