Fillable Applying For Paid Family Leave Care for Family (Daemen College)

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Applying For Paid Family Leave Care for Family (Daemen College)

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Applying For Paid Family Leave –
Care for Family Member
(Form PFL-1)
Care for a family member with a serious health condition
Complete Form PFL-1
• Complete PFL-1, Part A
• Provide PFL-1 to employer
• Employer completes PFL-1, Part B and returns to you within 3 days
Complete Form PFL-3
• Care recipient completes PFL-3 and provides to health care provider
• Care recipient’s health care provider keeps PFL-3
Complete Form PFL-4
• Complete “Employee” information at the top of PFL-4
• Provide PFL-4 to care recipient’s health care provider
• Care recipient’s health care provider completes PFL-4 and returns to you
Send forms and documents
• Send completed forms and supporting documentation to insurance carrier
• Insurance carrier accepts or denies claim within 18 days
Please keep a copy of all pages for your records.
To Use Paid Family Leave To:
Applying For Paid Family Leave – Care for Family Member
Page 1 of 1
If you need assistance, please call 800.535.2710
www.amtrustdb.com
DO NOT SCAN
Send completed form to:
Wesco Insurance Company
An AmTrust Financial Company
P.O. Box 980 at Bowling Green Station
New York, NY 10274
Email: dbclaims@amtrustgroup.com
or Fax: 800.584.9303
For inquiries:
Please call 800.535.2710
PART A - EMPLOYEE INFORMATION (to be completed by employee)
Paid Family Leave (PFL) Request (to be completed by the employee)
Employment Information (to be completed by the employee)
The employee requesting PFL must complete all required information.
Question 13: If dates are “Continuous”, the employee must provide
the start and end dates of the requested PFL. These dates should be
the actual dates that the PFL will begin and end. If uncertain, estimate
the start and end dates and indicate “Dates are estimated”. If dates are
“Periodic”, enter the dates PFL will be taken. Please be as specic as
possible. If the dates are unknown or estimated, indicate “Dates are
estimated”.
If dates are estimated, the PFL carrier may require you to submit a
request for payment after the PFL day is taken. Payment for approved
claims will be due as soon as possible but in no event more than 18 days
from the date of the completed request.
Question 14: If the employee is submitting the PFL request to their
employer with less than 30 days’ advance notice from the start date of
the PFL, the employee must explain why 30 days’ notice could not be
given. If the explanation will not t in the space provided on the form,
enter “See Attached” and add an attachment with the explanation. Be
sure to include the employee’s full name and their date of birth at the top
of the attachment.
Question 16: Enter the date of hire to the best of the employee’s
recollection. If it has been more than a year since the date of hire,
entering the year in which employment started is sufcient.
Question 18: Enter the best estimate of average gross weekly wage.
Include only the wages earned from the employer listed on this request
form. The gross weekly wage is the total weekly pay - including
overtime, tips, bonuses and commissions - before any deductions
are made by the employer, such as federal and state taxes. If the
employer is not able to supply this information, the employee can
calculate their gross weekly wage as follows:
Step 1: Add all gross wages received (before any deductions) over
the last eight weeks prior to the start of PFL, including overtime and
tips earned. (See Step 3 for instructions for calculating bonuses and/
or commissions.)
Step 2: Divide the gross wages calculated in step one by eight
(or the number of weeks worked if less than eight) to calculate the
average weekly wage.
Step 3: If the employee received bonuses and/or commissions
during the 52 weeks preceding PFL, add the prorated weekly amount
to the average weekly wage. To determine the prorated weekly
amount, add all bonuses/commissions earned in the preceding 52
weeks and then divide by 52.
Example of a gross weekly wage calculation:
Please note that the employer is also required to provide this information
in Part B of the Request For Paid Family Leave (Form PFL-1).
Form PFL-1 Instructions continued on next page
Week 1 - Gross wage including overtime $550
Week 2 - Gross wage $500
Week 3 - Gross wage $500
Week 4 - Gross wage $500
Week 5 - Gross wage $500
Week 6 - Gross wage $500
Week 7 - Gross wage, including overtime $600
Week 8 - Gross wage, including overtime $550
+________
Total: $4,200
Divide by 8:
÷_______8
Average Weekly Wage = $525
Bonus earned in preceding 52 weeks: $2,600
Divide by 52:
÷_____52
Prorated Weekly Bonus = $50
Average Weekly Wage = $525
Prorated Weekly Bonus = $50
+________
Average Weekly Wage (including bonus) = $575
Request For Paid Family Leave – Care for Family Member (Form PFL-1) Instructions
• To request PFL, the employee requesting PFL must complete Part A of the Request For Paid Family Leave (Form PFL1).
All items on the form are required unless noted as optional. The employee then provides the form to the employer to
complete Part B.
• The employer completes Part B of the Request For Paid Family Leave (Form PFL-1) and returns it to the employee within
three days.
• Additional forms are required depending on the type of leave being requested. The employee requesting leave is
responsible for the completion of these forms.
• The employee submits the completed Request For Paid Family Leave (Form PFL-1) with the required additional
form to the employer’s PFL insurance carrier listed on Part B of Request For Paid Family Leave (Form PFL-1).
The employee should retain a copy of each submitted form for their records.
Form PF1-1 Instructions
Page 1 of 2
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PART A - EMPLOYEE INFORMATION (to be completed by employee) – continued from prior page
FORM PFL-1 INSTRUCTIONS - CONTINUED FROM PRIOR PAGE
Form PFL-1 Instructions continued from prior page
If you are pre-submitting form: Indicate if the employee is pre-submitting their PFL request. Pre-submitting is dened as submitting the
application in advance of an upcoming qualifying event, with certain required information missing due to the information being unknown at
the time of the submitting. If pre-submitting is permitted by the carrier or self-insured employer, the missing information must be supplied as
soon as it is known. Benets cannot be determined until all of the required information is provided.
The PFL insurance carrier or self-insured employer will provide the employee a notice within ve days which 1) states the claim is pending;
2) identies what information is missing; 3) instructs how to submit the missing information. Once all information is supplied, the PFL
insurance carrier or self-insured employer has 18 days to pay or deny the claim.
If the carrier or self-insured employer does not permit pre-submitting, the carrier or self-insured employer must return the Request for Paid
Family Leave within ve days to the employee with an explanation that the claim should be re-submitted when all information is available.
Employee signs and dates, before giving this form to their employer to complete Part B.
Questions 2: If a Social Security Number is used for the Federal
Employer Identication Number (FEIN), enter the Social Security
Number.
Questions 3: Enter the employer’s Standard Industrial
Classication (SIC) Code. Contact your carrier if you don’t know
your SIC code.
Question 8: The employee occupation code can be found at:
www.bls.gov/soc/2010/soc_alph.htm
Question 9: Enter the wages earned by the employe during the
last eight weeks preceding the PFL start date. The gross amount
paid is the employee’s gross weekly pay, including any overtime
and tips earned for that week, plus the weekly prorated amount
of any bonus or commission received during the preceding 52
weeks. (For detailed steps, see Question 18 on page 1 of the
instructions.) Calculate the gross average weekly wage by adding
up the gross amounts paid, and then divide by eight (or number
of weeks worked if less than eight).
Question 10: Failure to select “Yes” for requesting
reimbursement from the insurance carrier, will result in a waiver of
the right to reimbursement.
Question 11a: ‘Disability’ refers to NYS statutory required
disability. If the answer is “none,” enter a “0” for total weeks and
days in Question 12b.
Question 11b: The maximum number of weeks available for
NYS statutory disability and PFL in any 52 week period is 26
weeks. Specify the total number of weeks, as well as the number
of additional days if the leave includes a partial week, taken for
NYS statutory disability and PFL during the preceding 52 weeks.
Question 13, 14 & 15: Enter the Paid Family Leave or Disability/
PFL insurance carrier’s name, address and PFL policy number.
If this employer is self-insured, enter the name and address of
where the PFL request should be submitted for processing.
PART B - EMPLOYER INFORMATION (to be completed by employer)
The employer of the employee requesting PFL must complete all information in Part B.
Afrmation employee is eligible for PFL: An employee who regularly works 20 hours or more per week must have been in employment
for at least 26 consecutive weeks. An employee who regularly works less than 20 hours per week must have worked 175 days.
Employee signs and dates, before giving this form to their employer to complete Part B.
Be sure to complete the appropriate additional PFL form(s)
based on the type of PFL leave being requested.
Notication Pursuant to the New York Personal Privacy Protection Law (Public Ofcers Law Article 6-A) and the Federal Privacy Act of 1974 (5 USC 552a).
The Workers’ Compensation Board’s (Board’s) authority to request that employees provide personal information, including their social security number or tax identication
number, is derived from the Board’s administrative authority under Workers’ Compensation Law section 142. This information is collected to assist the Board in investigating and
administering claims in the most expedient manner possible and to help it maintain accurate records. Providing your social security number or tax identication number to the
Board is voluntary. The Board will protect the condentiality of all personal information in its possession, disclosing it only in furtherance of its ofcial duties and in accordance
with applicable state and federal law.
Form PFL-1 Instructions
Page 2 of 2
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PART A - EMPLOYEE INFORMATION (to be completed by employee)
Paid Family Leave (PFL) Request (to be completed by the employee)
11. Reason for PFL request:
Bond with child
Care for family member
Military qualifying event
12. The family member is employee’s:
Child
Spouse
Domestic partner
Parent
Parent-in-law
Grandparent
Grandchild
Form PFL-1 continued on next page
Applying For Paid Family Leave –
Care for Family Member
(Form PFL-1)
INSTRUCTIONS INCLUDED WITH FORM
1. Employee’s legal name (rst name, middle initial, last name)
_______________________________________________________________________
2. Other last names, if any, under which employee has worked
_______________________________________________________________________
3. Employee’s mailing address
Street address
City, State
Zip code Country (if not U.S.A.)
4. Employee’s Social Security Number or TIN
-
-
5. Employee’s date of birth (MM/DD/YYYY)
/
/
6. Employee’s primary telephone number
(
)
-
7. Employee’s preferred email address while on PFL (if available)
_______________________________________________________________________
8. Employee’s gender
Male
Female
Not designated / Other
9. Employee’s preferred language
English
Español
Polski
Italiano
Kreyòl ayisyen
Other:
______________________________________________________________________
Optional (for research purposes)
10. Employee’s ethnicity/race
For purposes of health demographic only. (U.S. Centers for
Disease Control and Prevention (CDC) code set, version 1.0.)
Is employee of Hispanic, Latino/a, or Spanish origin?
(One or more categories may be selected.)
Mexican
Mexican American
Chicano/a
Puerto Rican
Dominican
Cuban
Another Hispanic, Latino/a, or Spanish origin
Not of Hispanic, Latino/a, or Spanish origin
Unknown
What is employee’s race?
(One or more categories may be selected.)
American Indian or Alaska Native
Black or African American
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
White
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacic Islander
Other race
Form PFL-1 (10-17)
Page 1 of 4
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PART A - EMPLOYEE INFORMATION (to be completed by employee) - continued from prior page
TO BE COMPLETED BY THE EMPLOYEE
Employee’s name
(rst name, middle initial, last name) __________________________________________________________________
Employee’s date of birth (MM/DD/YYYY)
/
/
Employment Information (to be completed by the employee)
Declaration and signature
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing
any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance
act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
I am hereby making a request for paid family leave benefits under the NYS Workers’ Compensation Law. My signature affirms that the information I am
providing is true and accurate to the best of my knowledge and belief.
_____________________________________________________________________________
/
/
Employee’s signature Date signed (MM/DD/YYYY)
I am submitting this form in advance (see instructions about pre-submitting). I understand the insurance carrier will contact me to advise how to submit the
required missing information.
FORM PFL-1 - CONTINUED FROM PRIOR PAGE
Form PFL-1 Instructions continued on next page
13. Will PFL be for a continuous period of time and/or periodic?
Continuous
PFL start date (MM/DD/YYYY) PFL end date (MM/DD/YYYY)
Dates are estimated
/
/
/
/
Periodic
Identify dates periodic PFL will be taken:
Dates are estimated
14. If providing less than 30 day’s advance notice to the employer, please explain:
___________________________________________________________________________________________________________________________________
15. Business name
_________________________________________________________________________________________________________________________________
16. Employee’s date of hire (MM/DD/YYYY)
/
/
17. Emplyee’s work location
Street address
City, State Zip code Country (if not U.S.A.)
18. Employee’s average gross weekly wage (This data will be requested of both employee and employer) _______________________________________________
19. Employer’s telephone number for contact regarding this request
(
)
-
20a. Does employee have more than one employer? Yes No
20b. If yes, is employee taking PFL from the other employer?
Yes No
21. Is employee currently receiving Workers’ Compensation Lost Wage Benets?
Yes No
Disclosure statement: Information regarding PFL benets received by the employee, such as payments received and types of leave, will be provided to the employer.
PFL-1 (10-17)
Page 2 of 4
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PART B - EMPLOYER INFORMATION (to be completed by the employer)
TO BE COMPLETED BY THE EMPLOYEE
Employee’s name
(rst name, middle initial, last name) __________________________________________________________________
Employee’s date of birth (MM/DD/YYYY)
/
/
FORM PFL-1 - CONTINUED FROM PRIOR PAGE
If employee contribution is withheld, indicate taxable % (employer portion) for the FICA deductions = ___________ %
1. Business’s full legal name and mailing address
Business name
Mailing address
City, State Zip code Country (if not U.S.A.)
2. Employer’s FEIN
-
3. Employer’s Standard Industrial Classication (SIC) Code
4. Employer’s contact name for questions related to PFL
______________________________________________________________________________________________________________________________________________________
5. Employer’s contact telephone number
(
)
-
6. Employer’s contact email address
___________________________________________________________________________________________________________________________________
7. Employee’s date of hire (MM/DD/YYYY)
/
/
8. Employee’s occupation Codes are available at: www.bls.gov/soc/2010/soc_alph.htm
-
9. Enter the last 8 weeks of gross wages for the employee and calculate the average gross weekly wage
Week no. Week ending date (MM/DD/YYYY) Number of days worked Gross amount paid
1
2
3
4
5
6
7
8
Calculated average gross weekly wage:
9a. Is the employee Full-time or Part-time?
Full-time Part-time
9b. If Part-time, is employee on PFL waiver?
Yes No
10. If employee received or will receive full wages while on PFL, will employer be requesting reimbursement?
Yes No
PFL-1 (10-17)
Page 3 of 4
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Form PFL-1 continued on next page
PART B - EMPLOYEE INFORMATION (to be completed by employer) - continued from prior page
TO BE COMPLETED BY THE EMPLOYEE
Employee’s name
(rst name, middle initial, last name) __________________________________________________________________
Employee’s date of birth (MM/DD/YYYY)
/
/
Declaration and signature
I afrm the employee regularly works 20 or more hours per week and has been in employment for at least 26 consecutive weeks OR the employee
regularly works less than 20 hours per week and has worked at least 175 days.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim
containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim
for each such violation.
I am the person authorized to sign as the employer of the employee requesting PFL. My signature affirms that to the best of my knowledge and belief, the
information I have provided is true and accurate.
___________________________________________________________________________________
/
/
Employer’s authorized signature Date signed (MM/DD/YYYY)
___________________________________________________________________________________
Title
FORM PFL-1 - CONTINUED FROM PRIOR PAGE
Form PFL-1 Instructions continued on next page
11a. In the preceding 52 weeks has the employee taken leave for: NYS Disability PFL Both Disability and PFL None
11b. Enter the total number of weeks and days taken for both Disability and PFL in the last 52 weeks:
Disability:
Weeks
Please provide specic dates for Disability:
Days
Disability:
Weeks
Please provide specic dates for Disability:
Days
12. Is the employee taking Family Medical Leave Act (FMLA) concurrently with PFL? Yes No
13. PFL insurance carrier’s name and mailing address
PFL insurance carrier’s name
Mailing address
City, State Zip code Country (if not U.S.A.)
14. PFL insurance carrier’s telephone number
(
)
-
15. PFL policy number ________________________________________________________________________________________________________________________________
PFL-1 (10-17)
Page 4 of 4
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Wesco Insurance Company
P.O. Box 980 at Bowling Green Station
New York, NY 10274
8 0 0 5 3 5 2 7 1 0
Release Of Personal Health Information Under
The Paid Family Leave Law (Form PFL-3) Instructions
• If an employee is requesting PFL to care for a family member with a serious health condition, the care recipient or an authorized
representative must complete a Release Of Personal Health Information Under The Paid Family Leave Law (Form PFL-3) and submit it
to their health care provider, along with a copy of the Health Care Provider Certication For Care Of Family Member With Serious Health
Condition (Form PFL-4).
• The Release Of Personal Health Information Under The Paid Family Leave Law (Form PFL-3) enables the health care provider to
complete Health Care Provider Certication For Care Of Family Member With Serious Health Condition (Form PFL-4) and release it to
the employee seeking PFL benets.
• Before completing and signing, the care recipient must read the Release Of Personal Health Information Under The Paid Family Leave
Law (Form PFL-3) in its entirety.
• The employee requesting PFL submits both the Request For Paid Family Leave (Form PFL-1) and the Health Care Provider Certication
For Care Of Family Member With Serious Health Condition (Form PFL-4) to their employer’s PFL insurance carrier, or to their employer
if the employer is self-insured, for PFL benet determination.
NOTE: This form will be retained by the health care provider. The employee should make a copy for their records before giving it to the
health care provider.
RELEASE OF PERSONAL HEALTH INFORMATION BY THE HEALTH CARE PROVIDER FOR A
FAMILY MEMBER WITH A SERIOUS HEALTH CONDITION (to be completed by the care recipient or
authorized representative and submitted to care recipient’s health care provider with Form PFL-4)
Care recipient or authorized representative signs and dates.
This form is given to the care recipient’s health care provider along with the
Health Care Provider Certication For Care Of Family Member With Serious Health Condition (Form PFL-4).
Form PFL-3 Instructions
Page 1 of 1
If you need assistance, please call 800.535.2710
www.amtrustdb.com
DO NOT SCAN
Notication Pursuant to the New York Personal Privacy Protection Law (Public Ofcers Law Article 6-A) and the Federal Privacy Act of 1974 (5 USC 552a).
The Workers’ Compensation Board’s (Board’s) authority to request that employees provide personal information, including their social security number or tax
identification number, is derived from the Board’s administrative authority under Workers’ Compensation Law section 142. This information is collected to assist
the Board in investigating and administering claims in the most expedient manner possible and to help it maintain accurate records. Providing your social security
number or tax identification number to the Board is voluntary. The Board will protect the confidentiality of all personal information in its possession, disclosing it
only in furtherance of its official duties and in accordance with applicable state and federal law.
Employee enters their name, and care recipient’s (patient’s) name and date of birth at the top of each page.
The PFL insurance carrier name requested at the top of the form is the same as the PFL insurance carrier identied in Request For Paid
Family Leave (Form PFL -1) Part B line 13.
Care recipient or authorized representative must complete all applicable requested information.
If a care recipient is unable to ll out this form, an authorized representative must attach a copy of legal documentation, such as a health
care proxy or power of attorney, permitting the representative to sign on behalf of the care recipient. The health care provider will require this
documentation of authorization unless the authorized representative is a parent signing on behalf of a minor child.
Request For Paid Family Leave
Release Of Personal Health Information
Under The Paid Family Leave Law (Form PFL-3)
INSTRUCTIONS INCLUDED WITH FORM
RELEASE OF PERSONAL HEALTH INFORMATION BY THE HEALTH CARE PROVIDER FOR A
FAMILY MEMBER WITH A SERIOUS HEALTH CONDITION (to be completed by the care recipient or
authorized representative and submitted to care recipient’s health care provider with Form PFL-4)
TO BE COMPLETED BY THE EMPLOYEE
Employee’s name (rst name, middle initial, last name)
______________________________________________________________________________________________________________________
Care recipient’s (patient’s name) (rst name, middle initial, last name) Care recipient’s (patient’s) date of birth (MM/DD/YYYY)
_________________________________________________________________
/
/
I,
Care recipient’s (patient’s) name
, authorize my health care provider listed on this form to
release my personal health information to
Employee name
and their
employer’s PFL insurance carrier
PFL insurance carrier’s name
.
Records Subject to Release: This form gives the health care provider listed permission to include information from your health care records on the
attached medical certication. This form gives your health care provider permission to release only the information in your health care records that relate
to your current condition, which is the subject of the employee’s request for Paid Family Leave benets.
Duration of Revocable Release: This authorization ends after one year, or when you revoke the release. You can cancel this release at any time. To
cancel, send a letter to the health care provider listed on this form.
This form does NOT allow your health care provider to release the following types of information, unless you specically permit such release. Put an “X”
next to any information your health provider MAY release:
HIV/AIDS related information Mental health information Alcohol/drug treatment Psychotherapy notes
Health Care Provider Information (to be completed by the care recipient or authorized representative)
Identify the health care provider who is currently providing you with treatment for a condition that is subject to the employee’s
request for PFL benets.
1. Health care provider’s name
____________________________________________________________________________________________________________________________________
2. Health care provider’s mailing address
Mailing address
City, State Zip code Country (if not U.S.A.)
3. Health care provider’s telephone number (provide area or country code)
____________________________________________________________________________________________________________________________________
Form PFL-3 continued on next page
Form PFL-3 (10-17) Release of PHI
Page 1 of 2
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DO NOT SCAN
RELEASE OF PERSONAL HEALTH INFORMATION BY THE HEALTH CARE PROVIDER FOR A
FAMILY MEMBER WITH A SERIOUS HEALTH CONDITION (to be completed by the care recipient or
authorized representative and submitted to care recipient’s health care provider with Form PFL-4) -
continued from prior page
FORM PFL-3 - CONTINUED FROM PRIOR PAGE
TO BE COMPLETED BY THE EMPLOYEE
Employee’s name (rst name, middle initial, last name)
______________________________________________________________________________________________________________________
Care recipient’s (patient’s name) (rst name, middle initial, last name) Care recipient’s (patient’s) date of birth (MM/DD/YYYY)
_________________________________________________________________
/
/
Care Recipient Information (to be completed by the care recipient or authorized representative)
Form PFL-3 continued from prior page
4. Care recipient’s mailing address
Mailing address
City, State Zip code Country (if not U.S.A.)
5. Care recipient’s Social Security Number
-
-
6. Care recipient’s telephone number (provide area or country code)
____________________________________________________________________________________________________________________________________
READ AND SIGN BELOW
I hereby request that the health care provider listed give a completed Health Care Provider Certication For Care Of Family Member With Serious Health Condition
(Form PFL-4) to the employee identied on the PFL-4 form. I understand that such information includes a diagnosis and prognosis of my current condition, the date it
commenced, and any estimation of the amount of care that I require from the employee requesting PFL benets as a result of my current condition.
Care recipient’s signature Date signed (MM/DD/YYYY)
_________________________________________________________________
/
/
Authorized representative
I,
Print name
, represent the care recipient in this matter as authorized by:
Parental right Power of attorney (attach copy) Court order (attach copy) Health care proxy (attach copy)
Authorized representative’s signature Date signed (MM/DD/YYYY)
_________________________________________________________________
/
/
The employee should retain a copy for their own records.
PFL-3 (10-17) Release of PHI
Page 2 of 2
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Health Care Provider Certication For Care Of Family Member
With Serious Health Condition (Form PFL-4) Instructions
The employee requesting PFL to care for a family member with a serious health condition must submit the Health Care Provider Certication
For Care Of Family Member With Serious Health Condition (Form PFL-4) with the Request For Paid Family Leave (Form PFL-1).
Employee:
• Employee enters their name, date of birth, other last names, if any, under which they have worked, Social Security or Taxpayer
Identication Number (TIN) number, mailing address, and care recipient’s (patient’s) name and date of birth at the top of page 1.
• Employee enters their name and date of birth, and care recipient’s (patient’s) name and date of birth at the top of page 2.
• Employee gives the Health Care Provider Certication For Care Of Family Member With Serious Health Condition (Form PFL-4) to the
health care provider.
HEALTH CARE PROVIDER CERTIFICATION FOR CARE OF FAMILY MEMBER WITH SERIOUS
HEALTH CONDITION (to be completed by the health care provider for the care recipient (patient)
and returned to the employee identied above)
Form PFL-4 Instructions
Page 1 of 1
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DO NOT SCAN
Notication Pursuant to the New York Personal Privacy Protection Law (Public Ofcers Law Article 6-A) and the Federal Privacy Act of 1974 (5 USC 552a).
The Workers’ Compensation Board’s (Board’s) authority to request that employees provide personal information, including their social security number or tax
identification number, is derived from the Board’s administrative authority under Workers’ Compensation Law section 142. This information is collected to assist
the Board in investigating and administering claims in the most expedient manner possible and to help it maintain accurate records. Providing your social security
number or tax identification number to the Board is voluntary. The Board will protect the confidentiality of all personal information in its possession, disclosing it
only in furtherance of its official duties and in accordance with applicable state and federal law.
Question 2: Providing the optional ICD-10 code is recommended.
The patient’s health care provider must complete the Patient Information and Health Care Provider sections of the Health Care Provider
Certication For Care Of Family Member With Serious Health Condition (Form PFL-4).
Health care provider signs and dates, and then returns the form to the employee requesting PFL.
If you believe the patient is the victim of abuse or neglect caused by
the employee requesting PFL, you may decline to provide this certication.
Patient Information / family member with serious health condition (to be completed by the health
care provider for the care recipient (patient) and returned to the employee identied above)
The patient’s health care provider must complete all applicable requested information unless noted as optional.
Employee:
• When you receive the completed Health Care Provider Certication For Care Of Family Member With Serious Health Condition (Form
PFL-4) form from the health care provider, send the completed forms and supporting documentation to the insurance carrier.
Request For Paid Family Leave
Health Care Provider Certication For Care Of Family
Member With Serious Health Condition (Form PFL-4)
INSTRUCTIONS INCLUDED WITH FORM
HEALTH CARE PROVIDER CERTIFICATION FOR CARE OF FAMILY MEMBER WITH SERIOUS
HEALTH CONDITION (to be completed by the health care provider for the care recipient (patient)
and returned to the employee identied above)
Patient Information / family member with serious health condition (to be completed by the health
care provider for the care recipient (patient) and returned to the employee identied above)
1. Does patient require care by the employee requesting Paid Family Leave (PFL)?
Yes No (If no, skip to “Health Care Provider Information”.)
Note: For the purposes of this section, “providing care” may include necessary physical care, emotional support, visitation, assistance in treatment, transportation, arranging for a
change in care, assistance with essential daily living matters, and personal attendant services.
2. Primary ICD-10 code (optional)
3. Diagnosis
______________________________________________________________________________________
4. Date patient’s condition commenced (MM/DD/YYYY)
/
/
5. First date care for patient is needed(MM/DD/YYYY)
/
/
6. Expected date patient will no longer require care (MM/DD/YYYY)
/
/
7. Estimated number of days per week OR days per month patient requires care
Days/week
or
Days/month
8. Health care provider’s name
______________________________________________________________________________________
Form PFL-4 continued from prior page
Form PFL-4 (10-17) HCP Certication
Page 1 of 2
If you need assistance, please call 800.535.2710
www.amtrustdb.com
DO NOT SCAN
TO BE COMPLETED BY THE EMPLOYEE
Employee’s name (rst name, middle initial, last name)
Employee’s date of birth (MM/DD/YYYY)
_______________________________________________________
/
/
Other last names, if any, under which employee has worked Employee’s Social Security Number or TIN
________________________________________________________
-
-
Employee’s mailing address
Mailing address
Mailing address Zip code Country (if not U.S.A.)
Care recipient’s (patient’s) name (rst name, middle initial, last name) Care recipient’s (patient’s) date of birth (MM/DD/YYYY)
________________________________________________________
/
/
Health Care Provider Information (to be completed by the health care provider for the care
recipient (patient) and returned to the employee identied above)
TO BE COMPLETED BY THE EMPLOYEE
Employee’s name (rst name, middle initial, last name)
Employee’s date of birth (MM/DD/YYYY)
_______________________________________________________
/
/
Care recipient’s (patient’s) name (rst name, middle initial, last name) Care recipient’s (patient’s) date of birth (MM/DD/YYYY)
________________________________________________________
/
/
FORM PFL-4 - CONTINUED FROM PRIOR PAGE
HEALTH CARE PROVIDER CERTIFICATION FOR CARE OF FAMILY MEMBER WITH SERIOUS
HEALTH CONDITION (to be completed by the health care provider for the care recipient (patient)
and returned to the employee identied above) - continued from prior page
9. Type of health care provider:
Medical Doctor (MD) Dentist (DDS/DDM) Licensed Social Worker (LMSW/LCSW)
Doctor of Osteopathy (DO) Physician’s Assistant (PA) Other (specify)
Doctor of Podiatric Medicine (DPM) Nurse Practitioner (NP)
Doctor of Chiropractic Medicine (DC) Licensed Psychologist
10. Health care provider’s mailing address
Mailing address
Mailing address Zip code Country (if not U.S.A.)
11. Health care provider’s telephone number (provide area or country code) _____________________________________________________________________
12. Health care provider’s fax number (provide area or country code) ____________________________________________________________________________
13. Health care provider’s email address (if available) ____________________________________________________________________________________
14. State or country (if not U.S.A.) in which health care provider is licensed to practice _____________________________________________________
15. Specialty ________________________________________________________________________________________________________________________
16. Health care provider’s license number ______________________________________________________________________________________________
PFL-4 (10-17) HCP Certication
Page 2 of 2
If you need assistance, please call 800.535.2710
www.amtrustdb.com
Certication and signature
Any person who knowingly and with intent to defraud any insurance company or other person les an application for insurance or statement of claim containing any
materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a
crime, and shall also be subject to a civil penalty not to exceed ve thousand dollars and the stated value of the claim for each such violation.
My signature attests that the information I have provided in this form is based on my professional assessment within my licensed scope of practice.
Health care provider’s signature Date signed (MM/DD/YYYY)
_________________________________________________________________
/
/
Form PFL-4 continued on next page
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Applying For Paid Family Leave Care for Family (Daemen College)

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Completed 29 January 2021

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