Guides · FMLA certification
Form WH-380-E, Certification of Health Care Provider for Employee’s Serious Health Condition: how to fill it out, field by field
This is the short version. The full walkthrough, with every page of the form shown and each item marked, is on my other site, The Physician’s Back Office. Read the full WH-380-E walkthrough.
Form WH-380-E is the Department of Labor’s form for an employee who needs time off under the Family and Medical Leave Act (FMLA) because of their own serious health condition. When HR asks your patient for an “FMLA certification form” or an “FMLA medical certification” for their own illness, this is the form they usually mean, or the employer’s own version of it, which can ask for the same information but no more. 29 C.F.R. § 825.306(b)
| Official name | Certification of Health Care Provider for Employee’s Serious Health Condition under the Family and Medical Leave Act |
|---|---|
| Current version | Revised June 2020, from the U.S. Department of Labor, Wage and Hour Division |
| Section I, page 1 | The employer, or the employee. It names the employee and the employer, gives the date the form is due back, and describes the job. |
| Section II, pages 2 to 4 | You, the clinician. Your patient is the employee, so on this form they are the same person. |
| Due back | At least 15 calendar days after HR asks for it |
| Where it goes | Back to your patient, who hands it to their employer. The form says in capitals not to send it to the Department of Labor. |
If you need a blank copy, download the official WH-380-E from the Department of Labor (PDF). If the leave is to look after a family member rather than for your patient’s own condition, the form is the WH-380-F, and I wrote a separate guide to the WH-380-F. For an overview of all the FMLA forms a doctor’s office sees, start with FMLA paperwork for doctors.
- Page 1 belongs to the employer. Your part starts at Section II on page 2, and if the employer left page 1 blank, you can leave it blank.
- Item 2, how long it will last: write a range in weeks or months. Avoid “unknown”, “lifetime” or “indeterminate”, which the form itself warns may not be enough.
- Item 9, time off in episodes: write both how often and how long each time. One number without the other is one of the most common reasons a form is not accepted.
- Item 3: check every box that fits, and fill in the lines under each box you check.
- Part C: name at least one core part of the job your patient cannot do. Time away for treatment counts.
- Item 4 is optional. I leave the diagnosis out, describe the symptoms and the time they cost, and never write family history or anything genetic.
Has this happened to you? A patient hands you a WH-380-E at the end of a fifteen-minute visit and asks if you can fill it out now, and you have two more patients waiting. On top of that, if an answer is vague or missing, HR may not accept the form, your patient has to come back to get it fixed, and their leave can be delayed or even denied.
This guide goes through the form the way I fill it out, item by item, with the rule behind each item so you can see why it asks what it asks. It describes what the form asks, not what you should certify. That judgment is always yours.
Before you start: who fills in what, and the deadlines
The WH-380-E is the Department of Labor's form for an employee who needs time off for their own serious health condition under the Family and Medical Leave Act (FMLA). The current version is the June 2020 revision. Page 1 is for the employer, though the form lets the employee fill it in instead, with the employee's name, job title, schedule and a description of the job. Your part starts at Section II on page 2 and runs to your signature on page 4. If the employer left page 1 blank, it is not your responsibility to fill it in.
Your patient has at least 15 calendar days from when HR asked for the form to get it back to them. If HR decides an answer is missing or too vague, they have to tell your patient in writing what is wrong and give them at least seven more days to get it fixed. If the corrected form still is not enough, the leave can be denied. So a form that is not accepted is at best a hassle for your patient and for you, and at worst it can cost them the leave. 29 C.F.R. §§ 825.305, 825.313
HR may contact you only to confirm that you completed the form or to ask what an answer means. They may not ask you for more information than the form asks for, and the contact may never come from your patient's direct supervisor. 29 C.F.R. § 825.307(a)
When the form arrives at the wrong moment
Here is what I do when the form comes out as the patient is getting up to leave. I take a minute to find out what the leave is for. Even when it is the problem we just talked about, I usually still need to ask a few questions about their job and how the condition affects it. If it will take more than about five minutes and there is no time, I say something like, “I want to help you with this. To fill it out so your HR will accept it, I need to ask you more questions than we have time for today, and I have other patients waiting. Let's book a visit in the next couple of days just for this form.”
The same goes for a form dropped off at the front desk with no word about why the leave is needed. I know my patient as of their last visit. If something new has happened since, I have no sound basis for what I am being asked to certify. In my experience it is better to have staff call the patient and schedule a visit within a couple of days than to piece the story together from an old note, because the 15 days are already running.
Two ideas the form assumes you already know
Nearly every box on the form rests on two ideas that medical training does not really cover. Once you have them, you see that the form is basically asking one question, which is whether your patient's medical situation is stopping them from doing one or more of the core duties of their job, and for how long.
The core duties of the job (essential job functions)
These are the things the job exists to do, such as a nurse lifting and turning patients, a truck driver driving, or an accountant working on spreadsheets. Tasks that could be handed to someone else, like restocking the supply room or covering the phone at lunch, are not core duties.
The question is not “can my patient work?” but “can my patient do this job?”, and the answer is no if they cannot do even one of its core duties. A warehouse worker four weeks out from knee surgery could sit at a desk, but if lifting is a core duty of their job, they cannot do their job, and that is the answer the form needs. Time away for treatment counts too, because during an infusion or a physical therapy session your patient is not doing their job. 29 C.F.R. §§ 825.123(a), 1630.2(n)
When the condition stops them working (incapacity)
For this form, incapacity means your patient cannot work because of the condition, because of its treatment, or while recovering from either. The day of bowel prep for a colonoscopy, the week after a cholecystectomy and the afternoon a migraine makes working impossible are each a period of incapacity. It comes in two shapes that the form asks about separately. One continuous stretch, such as recovery from surgery, goes in item 8. Episodes that come and go, such as flare-ups, go in item 9. 29 C.F.R. § 825.113(b)
Section II: your contact block
Print your name (the same name that signs page 4), your practice address, phone, fax and email, and your type of practice or specialty, for example family medicine or orthopedic surgery. HR uses this block if they need to confirm that you completed the form.
Part A: the medical facts
Item 1: when did the condition start?
Write your best estimate of when it began or will begin. A month and a year is fine, and so is “approximately 2019” for something long-standing.
Item 2: how long will it last?
Write a range in weeks or months, such as “six to eight weeks” or “three to six months”. For a condition that will not end, “ongoing, chronic condition” is a complete answer, as long as item 9 says how often the flare-ups come and how long each one lasts. In my experience it is simplest to give a range of no more than about six months, even for a lifelong condition, because HR can ask for a new certification periodically anyway, in most cases about every six months, and you fill out a new form then. 29 C.F.R. § 825.308
Avoid describing the time off as “unknown”, “indeterminate” or “lifetime”. The form itself warns that these may not be enough to decide whether FMLA applies. HR needs to know how much time off to approve so they can plan around it, and “lifetime” describes the disease rather than the time off.
Item 3: which kind of condition is it?
FMLA covers a serious health condition, and the form defines that as fitting at least one of six categories, not as your judgment of how ill your patient is. Minor illnesses such as a cold or an upset stomach usually do not count. Check every box that fits, and fill in the lines under each box you check, because a checked box with nothing written under it is a common reason a form is not accepted.
The box names sound like diagnoses, and that can be confusing. To a physician, diabetes is both chronic and permanent, but on this form it is one or the other depending on how it costs your patient time. So I read the six boxes as six patterns of lost time rather than six kinds of disease. One patient can fit several. Someone with Crohn's disease who was admitted for a flare, gets infusions every eight weeks, and misses a day or two whenever symptoms return fits inpatient care, multiple treatments and chronic conditions all at once, so you would check all three.
| Box | Check it when the lost time looks like this | Rule |
|---|---|---|
| Inpatient care | An overnight stay in a hospital, hospice or residential care facility, past or scheduled. The recovery at home afterwards is part of the same stretch. Write the admission dates. | § 825.114 |
| Incapacity plus treatment | More than three full days in a row unable to work, from an illness or procedure that then ends, such as a flu that kept them home a week. They also saw a clinician twice within 30 days, the first visit within 7 days, or once within 7 days and started ongoing treatment. Write the first and last days they could not work and the visit dates. Single days lost to a recurring problem belong under chronic conditions instead. | § 825.115(a) |
| Pregnancy | Any time the pregnancy keeps your patient from work, including prenatal visits. There is no four-day minimum. Write the expected delivery date. | § 825.115(b) |
| Chronic conditions | Bad days that come and go over months or years, with normal work in between, such as asthma attacks or migraines. The condition needs a clinician at least twice a year, and each lost day counts on its own, even if your patient was not seen that day. | § 825.115(c) |
| Permanent or long-term | Incapacity that treatment will not reverse, though a clinician still supervises it, such as Alzheimer's disease or the terminal stages of cancer, which are the form's own examples. | § 825.115(d) |
| Multiple treatments | The treatment itself costs the time, such as chemotherapy, radiation, dialysis or a course of physical therapy. It covers restorative surgery after an injury, or a condition that would keep your patient off work more than three days in a row if it went untreated. | § 825.115(e) |
What counts as ongoing treatment? The incapacity plus treatment box asks whether your patient started ongoing treatment. That means something you prescribed and are following, such as a course of prescription medication or a therapy that needs special equipment, like oxygen. Rest, fluids or over-the-counter medicine on their own do not count. 29 C.F.R. § 825.113(c)
Chronic, or permanent and long-term? This is the pair doctors mix up most. If your patient works most days but misses some because of flare-ups, check chronic conditions, even though the disease will never go away. Check permanent or long-term only when the condition keeps them from functioning all the time and treatment will not change that. Multiple sclerosis with an occasional relapse is chronic. If your patient needs a permanently shorter workday, say six hours instead of eight, that goes in item 7 whichever box you check.
None of the above. If none of the six fits, check this box, and be clear about what it means. You are telling the employer that the condition does not qualify for FMLA leave, and the leave will be denied. If that is the honest answer, it is the right one. But I would tell your patient before they hand the form in, so it is not their employer who breaks the news.
Item 4: anything else worth saying? (optional)
You may add facts that help explain the time off, such as symptoms, the treatment plan, or equipment like a nebulizer, but the form says plainly that you are not required to. This is the only box where a diagnosis could go, and the form's next sentence warns that some state and local laws may not allow you to disclose the diagnosis at all.
My approach is to leave the diagnosis out and describe the symptoms and the time they cost instead. The employer is not deciding what disease your patient has. They are deciding whether the time off is protected. One or two sentences in three parts usually does it: the symptoms that actually cost work, what those do to your patient on the job, and the treatment as time rather than as a drug. For example, “Recurring episodes of severe abdominal pain and urgent bowel frequency. During an episode they cannot stay on the production line and need immediate restroom access. A scheduled infusion every eight weeks, about four hours including travel.” That explains every box in Part B better than the name of the disease would, and it discloses nothing the employer has no business knowing.
Be especially careful with mental health conditions, substance use treatment and HIV status, which carry tighter privacy rules in many places. And never put genetic information or family history on this form. The federal Genetic Information Nondiscrimination Act (GINA) is why the form tells you not to. 29 C.F.R. §§ 825.306, 1635.3; 42 C.F.R. Part 2
Part B: how much time off
Item 5: planned appointments
Write the dates of scheduled visits if you know them, or the pattern, such as “monthly through March”. Time off for these appointments is protected, so listing them helps your patient. “Scheduled medical visits” plus the dates answers the question without disclosing more than it needs to.
Item 6: referrals to other clinicians
If you referred your patient elsewhere, write what for, the start and end dates of that treatment, and how long each visit takes including recovery. Be aware that a specialty name can give away the diagnosis, since “oncology” or “psychiatry” tells the employer what is wrong. When that is the case, I answer as a treatment schedule instead, such as “medical specialist evaluation and treatment, monthly” or “physical therapy, twice a week”.
Item 7: reduced hours
Fill this in only if your patient needs to work fewer hours for medical reasons. Write the dates and what they are able to work, in hours per day and hours per week. It asks for what they can do, not what they cannot.
Item 8: one continuous block of time off
Write a start date and an end date, including recovery. A best estimate is what is asked. If you truly cannot say yet, give a review date rather than leaving it empty, because an empty end date reads as “unknown”. For example, for a patient with severe back pain who is waiting three weeks to see a surgeon, I would write an end date one week after that appointment and add in item 4, “Length of time off depends on a specialist evaluation on [date]. I will re-evaluate after that visit.”
Item 9: time off in episodes
This is for conditions that flare up. Estimate, over the next six months, how often the flare-ups are likely to come (times per day, week or month) and how long each one keeps your patient off work (hours or days). You do not have a crystal ball, so this is your best educated estimate, and it needs both numbers. “Migraines about twice a month, one to two days each” is a complete answer. “As needed” is not.
This is where having your patient in the room matters most. I ask how often the flares have been coming and how long each one keeps them off work, and we settle the numbers together. An estimate from the chart alone is often too low for what the patient actually needs, and then the patient calls asking for the form to be amended.
Part C: what part of the job can they not do?
Item 10 asks whether your patient is unable to do any core duty of their job, and which one. If the employer described the job on page 1, answer against that description. If page 1 is blank, go by what your patient tells you the job involves. Being away for treatment counts as being unable to do the job for that time. A blank answer, or only “see above”, is a common reason a form is not accepted.
Your signature
Sign and date page 4 with the same name you printed in Section II. Your signature stands behind every estimate above it, so each one should be an estimate you would be comfortable explaining.
Why a WH-380-E is not accepted: the five usual suspects
- Item 2 says “unknown”, “lifetime” or “indeterminate”.
- Item 9 has how often but not how long, or the reverse.
- A box is checked in item 3 but the lines under it, such as the visit dates or the admission date, are empty.
- Part C is blank, or says only “see above”.
- The signature does not match the printed name, or the date is missing.
When the fix is small, you often do not need a new form. If only a number changes, say flare-ups go from once a month to twice a month, in my experience HR will usually accept the change on the original form. Cross out the old answer with a single line, write the new one beside it, initial and date it, and send it back.
The longer version
I also wrote a longer walkthrough of this form on my other site, The Physician's Back Office, with each page of the form shown and every item marked, plus what to do when your patient will not be going back to the job. Read the full WH-380-E walkthrough.
FAQ
Can I write "unknown" or "lifetime" for how long the condition will last?
I would avoid it. The form itself warns that "lifetime", "unknown" or "indeterminate" may not be enough to decide whether FMLA applies. A best-estimate range in weeks or months works, and for a condition that will not end, "ongoing, chronic condition" is a complete answer as long as item 9 says how often the flare-ups come and how long each one lasts.
Can the employer call me about the form?
Only to confirm that you completed it or to ask what an answer means. They may not ask you for more information than the form asks for, and the call may never come from your patient's direct supervisor (29 C.F.R. 825.307(a)).
Is an approximate start date acceptable?
Yes. Item 1 asks for your best estimate of when the condition began or will begin. A month and a year is fine, and so is "approximately 2019" for something long-standing.
What happens if HR says the form is incomplete?
HR has to tell your patient in writing what is missing and give them at least seven days to get it fixed. If the corrected form is still not enough, the leave can be denied (29 C.F.R. 825.305(c), 825.313). For a small change, such as a different number in item 9, HR will often accept the correction written on the original form, crossed out with a single line, initialed and dated.
Should I put the diagnosis on the form?
You do not have to. Item 4 is optional, and the form warns that some state and local laws may not allow you to disclose the diagnosis. My approach is to describe the symptoms and the time they cost instead, and never to write family history or genetic information.
What is the FMLA certification form?
It is the paper an employer can ask for to confirm that an employee’s leave is for a serious health condition. The Department of Labor publishes two optional versions, the WH-380-E for the employee’s own condition and the WH-380-F for a family member’s. An employer may use its own form instead, as long as it asks for the same basic information and nothing beyond what the regulations allow (29 C.F.R. 825.306(b)).
Is the WH-380-E the same thing as an FMLA medical certification?
Yes, it is one. “Medical certification” is the regulations’ name for what the clinician provides, and the WH-380-E is the Department of Labor’s form for providing it when the employee is the patient. When the patient is the employee’s spouse, parent or child, the form is the WH-380-F, which I cover in the WH-380-F guide.
Can I charge for completing the WH-380-E?
In most cases, yes. The regulations put the cost of the certification on the employee, and insurance rarely covers form completion. Payer contracts and some state rules can limit this, which the companion guide on charging for FMLA paperwork goes through. Can you charge for FMLA paperwork?
Disclaimer: This guide is general information about what Form WH-380-E and the FMLA regulations ask. It is not medical or legal advice, and it never tells you what to certify. You are the certifying provider and are responsible for the accuracy of everything you certify. Where I say “my understanding” or “in my experience”, that is one physician's reading, and rules change, so check the current form and regulations before you rely on it. References: WH-380-E (Rev. June 2020); 29 C.F.R. §§ 825.113–825.115, 825.123, 825.305–825.308, 825.313; 29 C.F.R. § 1635.3.
Fill out the WH-380-E in a few minutes.
Every item on that list of usual suspects is something software can catch before you sign. I built PatientPapers to make this paperwork faster and easier, because as a physician I know how much of it lands on us. It is my own product, so weigh this accordingly. It keeps your details on file, asks the questions above in plain English, including items 2 and 9 the way the form needs them answered, and fills in the real Department of Labor form for you to review and sign. Nothing you enter is sent anywhere. $250 per year or $25 per month, per certifying provider.