Page 2 of 5 Fs/f PFML-CERT-FORM (12/21) Employee - First Name Middle Name Last Name Claim Number Section 2: Certification of Serious Health Condition (Employee’s own medical or family member) To be completed by the healthcare provider. Patient's - First Name Middle Name Last Name Date of Birth (mm/dd/yyyy) (required) Gender ICD-10 Diagnosis Code Does the patient have a serious health condition that prevents them from performing the material and substantial duties of their job? Yes No Check and complete all that apply: Condition due to pregnancy Estimated Due Date (mm/dd/yyyy) Child's Date of Birth (mm/dd/yyyy) Place of Birth (city, state) Is the claimant pregnant (when condition itself is not pregnancy) ? Yes No Is the condition due to organ or bone marrow donation? Yes No Dates you treated patient for condition: Starting (mm/dd/yyyy) To (mm/dd/yyyy) Will patient need treatment visits at least twice per year due to condition? Yes No Expected duration of condition: Starting (mm/dd/yyyy) To (mm/dd/yyyy) Condition lead to hospital admittance: Starting (mm/dd/yyyy) To (mm/dd/yyyy) Intermittent absence details: Will the employee listed above require an intermittent absence and/or reduced work schedule to care for your patient’s (the employee/’s family member) serious health condition? If so, please check the box below and provide approximately how long your patient will need the intermittent support outlined below. Frequency: times per Week, Month Year Length of Episode Minutes Hours fully day(s) In the space provided below or in an attached page, please describe relevant medical facts, if any, related to the condition for which the employee seeks leave from work (i.e., pregnancy complications, or any regimen of continuing treatment such as the use of specialized equipment) .