How to Fill Out the Minnesota Paid Leave Medical Leave Certification Form

The Minnesota Paid Leave medical leave certification form is the document you submit with your benefit application when you need time off work for your own serious health condition. You complete the first section yourself, then give the form to your treating healthcare provider to fill out the medical portions. Once both parts are done, you upload the finished form at paidleave.mn.gov and submit a separate Paid Leave application through the same site.¹

You can file up to 60 days before your leave starts, or as soon as possible after it begins if you couldn’t apply ahead of time. The form has four sections. Only the first is yours.

Section 1: Your Information

Section 1 is the only part you complete. You’ll enter your full name, date of birth, phone number, residential address, and the last four digits of your Social Security number or your full Individual Taxpayer Identification Number.¹

The form also asks you to identify which job functions you are or will be unable to perform. The options are physical duties, cognitive duties, or other. Check every category that applies. This is what the state uses to match your reported limitations against your provider’s clinical assessment, so an incomplete answer here can create conflicts later. Sign and date this section before handing the form over.

Which Providers Can Complete the Form

The remaining three sections belong to your healthcare provider, and not every clinician qualifies. Under Minnesota law, qualifying providers include physicians, physician assistants, podiatrists, osteopaths, surgeons, advanced practice registered nurses, licensed alcohol and drug counselors, and mental health professionals.² If you see a specialist who doesn’t fall into one of these categories, check with Paid Leave before scheduling. The commissioner can authorize additional provider types by rule.

Section 2: The Health Condition

Your provider begins by selecting which category of serious health condition applies. The form lists six:

Inpatient care: hospitalization, hospice, or residential medical care, including any period of incapacity that follows.
Pregnancy: incapacity due to medical care related to pregnancy.
Incapacity of seven or more days: a condition keeping you out of work for at least seven calendar days, with either two or more provider visits within 30 days, or at least one visit resulting in ongoing treatment.
Chronic condition: requires periodic visits (at least twice a year), continues over an extended period, and may cause episodes of incapacity rather than one continuous absence.
Long-term condition: permanent or long-term, where treatment may not be effective but you remain under provider supervision.
Multiple treatments or recovery: absences for treatments such as restorative surgery after an injury, or for a condition that would cause more than seven days of incapacity without medical intervention.

These categories come directly from the statutory definition of serious health condition, which also covers substance use disorders. Both in-person and telemedicine visits count as treatment.³

After selecting the category, the provider enters the approximate date the condition started or will start, an estimate of how long it will last, and a description of other appropriate medical facts. A specific diagnosis is not required; the focus is on functional impact. The provider also answers whether the condition prevents you from performing the duties you identified in Section 1, and whether the condition is a job-related injury.¹

Section 3: The Leave Pattern

Here the provider describes the schedule of leave you need. There are three options:

Continuous leave: a single unbroken period away from work. The provider estimates how long the incapacity will last.
Reduced leave: fewer hours per week for a set period. The provider estimates hours off per week plus start and end dates.
Intermittent leave: multiple episodes that may be irregular or unexpected. The provider estimates how often episodes will occur (per day, week, or month), how long each episode will last, and explains why intermittent leave is medically beneficial.¹

Intermittent leave carries the heaviest documentation burden. The statute requires your provider to give a reasonable estimate of frequency and duration, plus an estimated treatment schedule if applicable.⁴ Vague answers like “as needed” or “varies” are the most common reason intermittent claims get sent back. Ask your provider for concrete numbers even if they are estimates.

Section 4: Provider Certification

Your provider finishes by entering their full name, title, area of practice or specialty, office mailing address, phone and fax numbers, and their license or practice number with the state or country of licensure. They sign and date this section, certifying that everything they’ve provided is accurate.¹

Some providers charge an administrative fee for completing certification forms, typically $25 to $75. Minnesota’s Paid Leave program does not reimburse these fees. Ask the office about the cost before you book the appointment.

Submitting the Completed Form

Once your provider returns the form, submit it to Minnesota Paid Leave. The form lists two submission methods:¹

Digital upload: if the form was completed electronically, upload the file directly at paidleave.mn.gov.
Photo or scan upload: if the form was printed, take clear photos or scan the completed pages and upload them through the same portal.

The certification form alone does not start your claim. You also have to submit a separate Paid Leave application at paidleave.mn.gov.¹ After submitting the application, you have 30 days to provide any required documentation, including the medical certification. Don’t wait until day 29. If the state needs corrections, that window doesn’t reset.

After You Submit

Most applications are processed within a couple of weeks, though claims that require additional information take longer.⁵ If the state finds problems with your certification, such as missing provider information, vague medical justifications, or conflicting dates, you’ll receive a request for information. The commissioner sets the deadline for your response, and if you don’t provide what’s asked within that timeline, your application is denied.⁶ Respond as quickly as you can. Delays at this stage push back your first payment.

If Your Certification Is Rejected

A denial notice will explain the reason and include appeal instructions. You have 30 calendar days from the date the determination is sent to appeal to the department. This applies whether the denial is based on missing documentation, financial eligibility, or the medical certification itself.⁷

If you miss the 30-day deadline, you can still request an appeal by demonstrating good cause, meaning something prevented a reasonable person acting with due diligence from filing on time. The deadline can be extended up to 60 days for good cause. If your employer uses an approved private plan instead of the state program and the private plan denies your request, you first request an administrative review from the plan within 30 days. If the plan upholds the denial, you can then appeal to the state department.⁸

1
Minnesota Department of Employment and Economic Development. Minnesota Paid Leave Medical Leave Certification Form
2
Minnesota Office of the Revisor of Statutes. Minnesota Statutes 268B.01 – Health Care Provider Definition
3
Minnesota Office of the Revisor of Statutes. Minnesota Statutes 268B.01 – Serious Health Condition
4
Minnesota Office of the Revisor of Statutes. Minnesota Statutes 268B.06 – Certification
5
KSTP.com 5 Eyewitness News. Paid Leave Applicants Taking Weeks to Approve
6
Minnesota Office of the Revisor of Statutes. Minnesota Statutes 268B.07 – Benefit Determination
7
Minnesota Office of the Revisor of Statutes. Minnesota Statutes 268B.081 – Appeals
8
Minnesota Office of the Revisor of Statutes. Minnesota Statutes 268B.10 – Private Plans