To claim benefits through Washington’s Paid Family and Medical Leave program, you (or a family member’s healthcare provider) submit a Washington paid leave medical certification form confirming the serious health condition behind your leave. You fill out the top section with your personal information, a licensed healthcare provider completes and signs the medical section, and you upload the finished form with your application at paidleave.wa.gov.1Washington State’s Paid Family and Medical Leave. Apply Now
Pick the Right Form for Your Leave Type
Washington uses different forms depending on why you’re taking leave. Using the wrong one means resubmitting paperwork and delaying your first payment.
Medical Leave or Family Caregiving Leave
If you’re taking leave for your own serious health condition, or family leave to care for a relative with one, use the Certification of Serious Health Condition form. Your healthcare provider completes it, confirming the diagnosis, expected duration, and whether the condition is chronic or temporary. You can download the form from the Employment Security Department’s Paid Leave website.2Washington State Paid Family and Medical Leave. Paid Leave Certification Forms
Birth and Bonding Leave
Both the birthing parent and the non-birthing parent can use the Certification of Birth form for bonding leave. Birthing parents can also use this form for medical leave during the postnatal period. It’s a short form: child’s date of birth, place of birth, and the provider’s signature. No medical certification is required for the postnatal period alone.3Paid Family and Medical Leave. Get Ready to Apply
Adoption, Foster Placement, or Military Exigency
These leaves don’t use a medical certification form at all. For bonding after adoption or foster placement, submit court documents showing the placement date, such as a court order or a letter from a social worker or agency.3Paid Family and Medical Leave. Get Ready to Apply For qualifying military exigency leave, you submit documentation of the family member’s active duty status rather than a medical form.4Washington State’s Paid Family and Medical Leave. Military Exigency Definition
What You Fill Out
The Certification of Serious Health Condition form has two main parts. The top section is yours: your personal information identifying who the leave is for. Fill this in before your appointment so your provider can go straight to the medical portion.2Washington State Paid Family and Medical Leave. Paid Leave Certification Forms
What the Healthcare Provider Fills Out
The provider handles the rest of the form and must answer three medical questions:2Washington State Paid Family and Medical Leave. Paid Leave Certification Forms
- Whether the patient has a serious health condition. The provider checks yes or no and, if yes, writes a brief description of the diagnosis. The condition must meet the definition in RCW 50A.05.010: generally, an illness, injury, or physical or mental condition involving inpatient care or continuing treatment by a healthcare provider.5Washington State Legislature. RCW 50A.05.010
- Pregnancy status: whether the patient is pregnant, the expected delivery date, and whether the patient has a pregnancy-related serious health condition such as severe morning sickness, preeclampsia, or recovery from a cesarean delivery.
- Expected duration: a start date and end date for the condition, or an indication that it is chronic or permanent.
If your leave is intermittent rather than continuous, the form asks for the expected frequency and duration of episodes. For migraines, a provider would note how often flare-ups occur and how many days each one keeps you from working.
The provider also supplies their full name, title, license number and state, area of practice, business name, address, phone number, and signature.
The provider doesn’t need to share your complete medical history. Their job is to confirm that a serious health condition exists and that it prevents you from doing your regular work (for medical leave), or that your family member’s condition requires your care (for family caregiving leave). The HIPAA minimum necessary standard applies, so the provider should disclose only what the form asks for.6U.S. Department of Health and Human Services. Summary of the HIPAA Privacy Rule
Who Can Sign the Form
Washington accepts certification from a range of licensed healthcare professionals, not just medical doctors. Any of the following can sign as long as they hold an active license and are practicing within their scope:7Washington State’s Paid Family and Medical Leave. Health Care Providers
- Physicians and osteopathic physicians
- Nurse practitioners and physician assistants
- Nurse-midwives and midwives
- Clinical psychologists and clinical social workers
- Dentists, podiatrists, optometrists, and physical therapists
Before You Submit: Check the Signature
An unsigned form will be rejected. That’s the most common paperwork error on these certifications and the easiest one to prevent. Before you leave the appointment or the form leaves the provider’s office, confirm the provider signed it and filled in their license number, business address, and phone number.
Look over the medical section too. If a date range is missing, if the pregnancy question is left blank when it applies, or if the diagnosis line has no description, send it back to the provider before submitting. An incomplete form will bounce back to you, and every round trip adds time to your first payment.1Washington State’s Paid Family and Medical Leave. Apply Now
Submitting the Form With Your Application
The certification isn’t submitted on its own. It goes in as part of your benefit application. The fastest route is uploading it directly through your online account at paidleave.wa.gov during the application flow.1Washington State’s Paid Family and Medical Leave. Apply Now You’ll also provide basic identifying information (legal name, Social Security Number or ITIN), verify your employment history, and upload a photo ID such as a driver’s license, state ID, passport, or military ID.8Washington State’s Paid Family and Medical Leave. Identification Verification Documents
If you can’t apply online, you can fax the completed forms to 833-535-2273.9Washington State’s Paid Family and Medical Leave. Family Leave Certification If you don’t have an SSN or ITIN, contact the department to request a paper application.
You also need to give your employer written notice, separate from the certification: at least 30 days ahead for foreseeable leave (planned surgery, an expected due date), and as soon as you can for unexpected leave. An email, text message, or handwritten note works. The notice only needs to say you’re taking Paid Leave and roughly how long you expect to be out.10Washington State’s Paid Family and Medical Leave. How Paid Leave Works
If the Department Needs More Information
If something on your application or certification is unclear, the department will contact you for more information. That back-and-forth adds time, which is why it’s worth double-checking every field, and the provider’s signature, before you submit.1Washington State’s Paid Family and Medical Leave. Apply Now
If Your Claim Is Denied
You can request a review if your application is denied or you disagree with the decision. Log into your benefit account, go to the Claim Reviews section, click Request Review, select your claim, explain why you think the decision should change, and upload any supporting documents (including a corrected or more detailed certification if that was the issue).11Washington State’s Paid Family and Medical Leave. After You Apply
If you applied on paper and don’t have an online account, request a review by phone at 833-717-2273, Monday through Friday, 8:30 a.m. to 4:30 p.m. Reviews are processed in the order received. A specialist may contact you for additional information before issuing a written decision letter.