Benefit Forms

Dependent Verification Requirements

Domestic Partnership Affidavit

Certification of Healthcare Provider Form (LOA-Related Form)

This form must be completed by you and your doctor and submitted for your own medical leave or pregnancy and childbirth leave to certify your medical or pregnancy disability. This form should also be completed by your family member’s doctor if you are taking a care of a family member leave.

Healthcare Provider Status Form (LOA-Related Form)

This form must be completed by you and your doctor immediately prior to your return to work. The completed form should indicate if you are able to return to work with no restrictions or if any specific restrictions are required. This form only applies to your own medical leave.