Follow the steps to complete the form seamlessly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Part I: Patient Information. Fill in the employee's last name, first name, middle initial, and employee number. Ensure the date is entered correctly.
3. Proceed to Part II: Certification Relating to the Employee’s Own Serious Health Condition. The physician or health care provider must indicate the dates of absence with their beginning and end dates.
4. Continue with detailing the employee’s serious health condition. Provide the date the condition commenced, the diagnosis, and a breakdown of the treatment regimen.
5. In Part III: Certification Relating to Care for a Seriously Ill Family Member, include the family member's name and relationship to the employee.
6. Continue by indicating if the family member requires assistance for basic needs and if the employee's presence is necessary for care.
7. Finally, fill out Part IV: Authorization. The physician or health care provider must print their name, sign the document, and provide their phone number, date, and specialization.
8. Review all sections of the form to ensure completeness and accuracy. Once finished, you can save changes, download the form, print, or share it as required.

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