FMLA covers care for a spouse, child, or parent with a serious health condition

Your employer may request a second medical opinion at their expense

You can take intermittent FMLA leave when medically necessary

Employment / FMLAmoderateDoctor signature required

FMLA Certification - Family Member's Serious Health Condition

WH-380-F · U.S. Department of Labor

Certification of Health Care Provider for Family Member's Serious Health Condition. Medical certification when employee needs leave to care for a family member.

Form Details

Total fields: 38
Auto-fillable: 20 (53%)
Time without BeneFill: 30 minutes
Time with BeneFill: 8 minutes
Time saved: 22 minutes
Filled by: doctor
Frequency: per incident

Fill this form with BeneFill

Auto-fill 53% of fields from your profile. Save 22 minutes. Download a real PDF.

20 of 38 fields53% auto-filled

Start Filling Upload Your Copy Instead Download blank official form

Where to Submit This Form

📬

Return to your employer's HR department

Hand-deliver to HR or supervisor.

📧

Email to HR if accepted electronically

Filing Deadline

Within 15 calendar days of your employer's request for family member medical certification.

Required Attachments

📎 Must be completed by the family member's healthcare provider
📎 Documentation of your relationship to the family member (if requested)

Processing Time

Employer must respond within 5 business days of receiving a complete certification.

What Happens Next

If approved, you are entitled to up to 12 weeks of job-protected leave to care for your family member. Employer must maintain your health insurance during FMLA leave.

Tips for This Form

✓ FMLA covers care for a spouse, child, or parent with a serious health condition
✓ Your employer may request a second medical opinion at their expense
✓ You can take intermittent FMLA leave when medically necessary
✓ Learn more about family FMLA rights at https://www.dol.gov/agencies/whd/fmla

More Employment / FMLA Forms

FMLA Certification - Employee's Serious Health Condition

WH-380-E · U.S. Department of Labor

Certification of Health Care Provider for Employee's Serious Health Condition. Medical certification for FMLA leave for the employee's own condition.

FMLA Notice of Eligibility and Rights & Responsibilities

WH-381 · U.S. Department of Labor

Notice of Eligibility and Rights & Responsibilities. Employer must provide within 5 business days of FMLA leave request, stating whether employee is eligible.

FMLA Designation Notice

WH-382 · U.S. Department of Labor

Designation Notice. Employer designates leave as FMLA-qualifying or denies it. Must be provided within 5 business days of receiving sufficient certification.

FMLA Certification - Qualifying Exigency (Military)

WH-384 · U.S. Department of Labor

Certification of Qualifying Exigency for Military Family Leave. For leave due to a covered family member's active duty or call to active duty.

FMLA Certification - Serious Injury/Illness of Servicemember

WH-385 · U.S. Department of Labor

Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave (current servicemember).

FMLA Certification - Serious Injury/Illness of Veteran

WH-385-V · U.S. Department of Labor

Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave.

Not sure which forms you need?

Tell our assistant about your situation and we'll find the right forms for you.

Chat with Form Assistant

Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the U.S. Department of Labor or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.