The DC FMLA form known as the PFL-MMC is the medical certification the Office of Paid Family Leave (OPFL) requires before it will pay benefits for your own serious health condition. You complete Part 1 with your name, your healthcare provider completes Part 2 (Sections A through D) documenting your diagnosis and the leave you need, and you upload the signed form through the claims portal at does.pflbas.dc.gov.1DC Paid Family Leave. Apply
Where to Get the Form
Download the current PFL-MMC from dcpaidfamilyleave.dc.gov or from inside the online claims portal.2District of Columbia – Paid Family Leave. District of Columbia – Paid Family Leave It is a fillable PDF. Print it or save it to send to your healthcare provider. If you cannot access the form online, call the OPFL contact center at (202) 899-3700 to request a copy.
Give your provider real lead time. The form warns that incomplete sections will be returned, and a rushed appointment usually produces exactly the blank fields that cause delays.
Part 1: The Employee Section
Part 1 is short. It asks for your first name, middle name, and last name. That is how OPFL matches the certification to your existing claim, so your name must appear exactly as it does on your benefits application.3DC Paid Family Leave. DC Paid Family Leave Medical Certification Form If you applied under a legal name that differs from the one your doctor has in their records, resolve the discrepancy before your provider starts Part 2. A mismatch here can hold up an otherwise complete file.
Part 2: The Healthcare Provider Section
Part 2 is where claims succeed or fail. Your healthcare provider fills out four subsections. Any provider you use must be a licensed healthcare professional who is currently treating you for the specific condition on the form.
Section A: Provider Information
Your provider enters their name, mailing address, phone number, email, type of practice or medical specialty, and state license number. A National Provider Identifier (NPI) is optional. The form has a field for the provider’s state, so an out-of-state specialist can complete it.4DC Department of Employment Services. DC Paid Family Leave Medical Certification Form
Section B: Qualifying Medical Condition
This is the most detailed part of the form. Your provider supplies the name of the diagnosis or a description of symptoms, the primary ICD-10 diagnostic code, and the date the condition was diagnosed. They then check the single box that best fits the category of your condition and answer every sub-question under it:3DC Paid Family Leave. DC Paid Family Leave Medical Certification Form
- Pregnancy, with the expected delivery date.
- Overnight inpatient care, with the dates of admission.
- Chronic condition, noting whether it requires two or more medical visits per year and whether unpredictable episodes are expected.
- Permanent incapacity requiring continuing supervision by a provider.
- Restorative surgery involving multiple treatments for the same injury or accident.
- Preventative treatment, with at least two treatment dates by a provider.
- Stillbirth, with the date of stillbirth.
- Incapacity plus treatment, with start and end dates of at least three consecutive days of incapacity, dates of in-person or telehealth appointments, and whether the condition resulted in a regimen of continuing treatment.
The “incapacity plus treatment” box is where the statute’s three-consecutive-day requirement appears in practice. If your provider checks it but leaves the dates vague, OPFL will send the form back.4DC Department of Employment Services. DC Paid Family Leave Medical Certification Form
Section C: Amount of Leave Needed
Section C asks your provider to specify the pattern of leave you need. There are three options, and more than one can be checked if your situation calls for it:3DC Paid Family Leave. DC Paid Family Leave Medical Certification Form
- Continuous incapacity: a single unbroken period away from work, with start and end dates. If the end date is uncertain, your provider gives a best estimate.
- Planned medical treatments: specific appointment dates, past or future.
- Intermittent incapacity: episodes of inability to work that come and go. If dates are unknown, the provider indicates whether unpredictable flare-ups are expected.
The distinction between continuous and intermittent leave changes how you report time off and how partial-week payments are calculated, so it is worth confirming with your provider that the box checked here reflects how you actually expect to be out.
Section D: Certification and Signature
Your provider signs and dates the form, certifying that they are a licensed healthcare provider currently treating you and that the information is true and complete.4DC Department of Employment Services. DC Paid Family Leave Medical Certification Form An unsigned form is automatically invalid. Confirm the signature and date are on the document before you leave the office.
How to Submit the PFL-MMC
Upload a scanned or photographed copy of the completed form through the DC PFL benefits portal at does.pflbas.dc.gov.1DC Paid Family Leave. Apply This is the fastest submission method. If you cannot submit online, call (202) 899-3700 for alternative filing options.
Before you upload, review the form one more time. Confirm that every sub-question under Section B’s checked category is answered, that Section C has dates, and that Section D is signed.
What Happens After You Submit
OPFL will contact you within 10 business days of receiving your application and supporting documents. During that window, staff review your medical certification, verify the provider’s information, and notify your employer that a claim has been filed.1DC Paid Family Leave. Apply You can track your claim status through the portal, and OPFL will notify you of the decision through the portal and by your preferred contact method, email or postal mail.
If the form is incomplete or the medical details are unclear, OPFL sends it back with a request for additional information rather than approving or denying the claim outright. This is the most common source of delay and can add days or weeks to your timeline. Treat Section B like a checklist: every sub-question answered, every date filled in.
If Your Claim Is Denied
You have 60 calendar days from the date of the written determination to file an appeal with the DC Office of Administrative Hearings (OAH).5Office of Administrative Hearings. Paid Family Leave You can also ask OPFL to reconsider the decision first. If that route produces a new determination, the 60-day clock resets from the date of that new decision.
To file the appeal, submit two documents to OAH: a completed Paid Family Leave Benefits Appeal Form and a copy of the specific determination you are appealing. If you forget the determination, OAH will order you to provide it by a deadline, and missing that deadline can get your case dismissed.5Office of Administrative Hearings. Paid Family Leave After OAH accepts your filing, you receive a scheduling order with your hearing date. Bring any evidence that supports your claim: medical records, correspondence with OPFL, and an updated PFL-MMC if the original was deficient.
A Note on Job Protection
DC Paid Family Leave provides cash benefits while you are away from work, but it does not by itself guarantee your job will be held for you. Job protection comes from separate laws, the federal Family and Medical Leave Act (FMLA) and the DC FMLA. If you qualify under one of those statutes, you can run your FMLA leave and your DC PFL benefits at the same time: FMLA protects your position while PFL replaces part of your income. Check with your employer about FMLA eligibility before assuming your position is secure during your leave.