Fillable Form WH-380-F
Form WH-380-F, Certification of Health Care Provider for Family Member's Serious Health Condition, is used by employees to request FMLA leave to care for a covered family member who is currently afflicted with a serious health condition. It provides employees a 12-week time off with no fear of demotions or being fired from the company they are working in.
What is Form WH-380-F?
Form WH-380-F, Certification of Health Care Provider for Family Member's Serious Health Condition, is a document used by an employee who wants to request family and medical leave (FML) from his or her employer to take care of a family member who has a serious health condition.
An employee must be eligible according to the Family and Leave Medical Act (FMLA) to request an FML. The Family and Leave Medical Act (FMLA) is a United States labor law that provides eligible employees a 12-week, job-protected time off from work. It protects employees from getting demoted, fired, or disciplined by their employers while on leave.
How to fill out Form WH-380-F?
Form WH-380-F must be filled out in the following order:
1. employer;
2. employee; then
3. health care provider.
A health care provider may not fill out Form WH-380-F that is not yet signed by both the employer and the employee.
SECTION I
This section is for the employer's use only.
Employer name and contact
Enter your name and contact information.
SECTION II
This section is for the employee's use only.
Your name
Enter your name.
Name of family member for whom you will provide care
Enter the name of your family member who needs care.
Relationship of family member to you
Enter your relationship with the family member.
If family member is your son or daughter, date of birth
Enter the birthdate of the family member if he or she is your son or daughter; otherwise, leave it blank.
Describe care you will provide to your family member and estimate leave needed to provide care:
Provide descriptions of the care you will provide to your family member. Then, enter the leave duration you will need for it.
Employee Signature
Enter your signature.
Date
Enter the date upon signing Form WH-380-F.
SECTION III
This section is for the health care provider's use only.
Provider's name and business address
Enter your name and business address.
Type of practice/Medical specialty
Enter your medical specialty or type of practice.
Telephone
Enter your telephone number.
Fax
Enter your fax number.
PART A: MEDICAL FACTS
Enter medical facts about the family member or patient.
1. Approximate date condition commenced
Enter the date the patient's condition commenced.
Probable duration of condition
Enter the probable duration of the patient's condition.
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
Mark Yes, if the patient was admitted for an overnight stay in a hospital, hospice, or residential medical care facility. Then, enter the date of admission. If not, mark No.
Date(s) you treated the patient for condition
Enter the dates you treated the patient’s condition.
Was medication, other than over-the-counter medication, prescribed?
Mark Yes, if there is a medication prescribed other than the over-the-counter; otherwise, mark No.
Will the patient need to have treatment visits at least twice per year due to the condition?
Mark Yes, if the patient’s condition will require him or her to have treatment visits at least twice per year; otherwise, mark No.
Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)?
Mark Yes if the patient was referred to other health care providers for evaluation or treatment. Then, enter the nature of such treatments and their expected treatment duration. If not, mark No.
2. Is the medical condition pregnancy?
Mark Yes, if the patient’s medical condition is pregnancy. Then enter the expected delivery date. If not, mark No.
3. Describe other relevant medical facts, if any, related to the condition for which the patient needs care (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):
Provide descriptions of other relevant medical facts related to the condition for which the patient needs care.
PART B: AMOUNT OF CARE NEEDED
Consider other factors such as basic assistance for medical, hygienic, nutritional, safety, or transportation needs in calculating the amount of care needed by the patient.
4. Will the patient be incapacitated for a single continuous period of time, including any time for treatment and recovery?
Mark Yes, if the patient will be incapacitated for a single continuous period, including any time for treatment and recovery; otherwise, mark No.
Estimate the beginning and ending dates for the period of incapacity:
Enter the starting and ending dates of the patient's period of incapacity.
During this time, will the patient need care?
Mark Yes if the patient currently needs care; otherwise, mark No.
Explain the care needed by the patient and why such care is medically necessary:
Provide an explanation regarding the care needed by the patient and why such care is medically necessary.
5. Will the patient require follow-up treatments, including any time for recovery?
Mark Yes if the patient is required for follow-up treatments, including any time for recovery; otherwise, mark No.
Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period:
Enter the patient's treatment schedule. Include the dates of any scheduled appointments and the time required for each, including any recovery period.
Explain the care needed by the patient, and why such care is medically necessary:
Provide an explanation regarding the care needed by the patient and why such care is medically necessary.
6. Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery?
Mark Yes if the patient will require care on an intermittent or reduced schedule basis, including any time for recovery; otherwise, mark No.
Estimate the hours the patient needs care on an intermittent basis, if any:
Enter the hours the patient needs care on an intermittent basis, including the hours per day, the number of days per week, and the starting and ending date.
Explain the care needed by the patient, and why such care is medically necessary:
Provide an explanation regarding the care needed by the patient and why such care is medically necessary.
7. Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily activities?
Mark Yes, if the patient's condition will cause episodic flare-ups that will periodically prevent him or her from participating in normal daily activities; otherwise, mark No.
Based upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of flare-ups and the duration of related incapacity that the patient may have over the next 6 months
Enter the patient's frequency of flare-ups and the duration of related incapacity that he or she may have over the next six months.
Does the patient need care during these flare-ups?
Mark Yes if the patient needs care during flare-ups; otherwise, mark No.
Explain the care needed by the patient, and why such care is medically necessary:
Provide an explanation regarding the care needed by the patient and why such care is medically necessary.
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.
Enter additional information about the patient's medical condition and the amount of care he or she needs. Identify the number of the question you want to add an answer to.
Signature of Health Care Provider
Enter your signature.
Date
Enter the date upon signing Form WH-380-F.
Who can file a medical and family leave?
To file a medical and family leave under the FMLA, you must:
How to file Form WH-380-F?
Do not submit Form WH-380-F to the U.S. Department of Labor. The health care provider must give the accomplished Form WH-380-F to the employee or the patient. Then, the employee may submit it to his or her employer to file a family and medical leave.
Employers must retain a copy of the submitted Form WH-380-F in their records for three years to minimize or prevent any paperwork burden required under the Paperwork Reduction Act (PRA) of 1995.
What is the Paperwork Reduction Act?
The Paperwork Reduction Act (PRA) of 1995 is an act that aims to minimize the paperwork burden for individuals, businesses, educational and nonprofit institutions, federal contractors, state, local and tribal governments, and other persons resulting from the collection of information by or for the federal government.
It also aims to ensure the maximum utility and quality of federal information and improve the federal government's accountability for managing information collection activities.