The Minnesota Paid Leave caring leave certification form is the document you use to prove that a family member has a serious health condition requiring your care. You download it from paidleave.mn.gov, fill out the applicant section yourself, hand it to the family member’s healthcare provider to complete and sign the medical portion, then upload the finished form through your Paid Leave account or mail it in with your benefits application.
The form does two jobs at once. It identifies you and your relationship to the person you’ll be caring for, and it documents the medical facts a state reviewer needs to confirm the condition qualifies. Getting either half wrong is the most common reason applications stall.
Confirm the Relationship Qualifies
Before you complete anything, make sure your relationship to the care recipient fits one of the categories Minnesota law recognizes under Chapter 268B. The statute is broader than many state programs.
The qualifying relationships include:
- Spouse or domestic partner
- Child, including biological, adopted, foster, stepchild, child of a domestic partner, or a child you serve as legal guardian or de facto custodian for
- Parent, including biological, adoptive, foster, stepparent, legal guardian, someone who stood in loco parentis when you were a child, and your spouse’s parents
- Sibling
- Grandchild or grandparent, including your spouse’s grandparents
- Son-in-law or daughter-in-law
- Someone with a personal relationship that creates an expectation you would care for them without compensation, whether or not you live together
That last category covers close friends, longtime unmarried partners, and others who function as family. If you’re relying on it, expect the state to look more closely at whether the bond meets the statutory standard. The form asks you to identify your relationship, so choose the category that actually applies.
Confirm the Condition Qualifies
A serious health condition under Minnesota law means a physical or mental illness, injury, impairment, or substance use disorder that involves either inpatient care (hospitalization, hospice, or residential medical care) or continuing treatment by a healthcare provider. Continuing treatment includes:
- Conditions causing at least seven consecutive days of incapacity followed by ongoing care
- Chronic conditions requiring periodic provider visits at least twice a year
- Pregnancy-related incapacity
- Long-term conditions where treatment may not be effective
- Absences for multiple treatments such as chemotherapy or physical therapy after surgery
A short-lived illness like a bad cold won’t qualify. A surgery requiring a week of recovery and follow-up appointments will. The provider filling out the medical section will need to document enough clinical detail for the state to confirm the threshold is met.
Complete the Applicant Section
Download the form from paidleave.mn.gov. It’s also available through the Individuals and Families Toolkit page on the same site. You complete the first section yourself before handing it off.
You’ll be asked for:
- Your name as it appears on official documents like a state ID, driver’s license, or W-2
- The last four digits of your Social Security number, or your full Individual Taxpayer Identification Number
- Your phone number and residential address
- The family member’s name as it appears on their official documents
- The family member’s date of birth
- Your relationship to the family member, chosen from the program’s categories
The form asks only for the last four digits of your SSN, not the full number. Match your name exactly to what appears on government-issued ID. A mismatch between your form and your employer’s payroll records is an easy way to trigger a delay.
You also indicate whether you’ll take leave in one continuous block or intermittently. Decide before handing the form off, because if you choose intermittent leave, the provider needs to include estimated frequency and duration of care episodes in their section.
The Healthcare Provider’s Section
The second half of the form is completed by the provider treating your family member, not your own doctor. The provider must supply a license or practice number, phone, office fax, and practice address. The form warns that it will not be accepted without a license number.
The provider documents:
- The date the condition began and its expected duration
- Medical facts about the condition sufficient for the state to confirm it meets the serious health condition standard
- Whether your physical presence is necessary to provide care, including help with basic medical, hygienic, nutritional, or safety needs, or psychological comfort during treatment or recovery
- For intermittent leave, the estimated frequency of care episodes and how long each is expected to last
The provider signs and dates the form to certify the information. An unsigned form is rejected outright. Ask the provider to complete every field. Incomplete medical sections are the most common reason the state requests additional documentation.
If your family member lives outside the United States, you can submit certification from a provider in their country, using either the Minnesota Paid Leave caring leave form or the federal FMLA/DOL form. Verifying a foreign provider takes 8 to 12 weeks, and if the state cannot verify the certifier, the application will be denied.
Submit the Form With Your Application
Once both sections are complete and signed, submit the form alongside your Paid Leave application. Uploading digitally through your account at paidleave.mn.gov is the fastest option. Paper forms can be scanned or photographed and uploaded, or mailed in.
The certification form by itself does not start your claim. You must also file a separate Paid Leave application through the portal. If you’ve already applied and are adding the certification afterward, upload it through your account or send it by mail.
There is no waiting period. Once leave is approved, benefits are designed to pay from the start of your leave. The state estimates eligibility determinations within about two weeks of receiving a complete application with all supporting documents. Check your Paid Leave account regularly after submitting; responding quickly to any request for more information keeps your timeline on track.
If Something Goes Wrong
If the state denies your application, you’ll receive a determination notice through your Paid Leave account explaining why. Common reasons include incomplete certification forms, a condition that doesn’t meet the serious health condition threshold, and an unverifiable healthcare provider. The notice will tell you whether you can reapply with corrected information or need to file a formal appeal, along with any applicable deadlines.
Penalties for False Information
Submitting false information on the certification form has consequences. If the state determines you were overpaid because of an intentional false statement or fraudulent representation, you must repay the overpaid amount plus a 15 percent penalty. Interest accrues at 6 percent per year on any balance remaining unpaid 30 days after the overpayment determination. In more serious cases, obtaining benefits through fraud can be prosecuted as theft: a gross misdemeanor if the amount is $500 or less, a felony if it exceeds $500.
An honest mistake or a good-faith error about your eligibility is not misrepresentation. The penalty applies only to intentional fraud.