[Free checklist] How to review a medical leave request

Even if your company has a clear medical leave policy and understands its FMLA obligations and state law requirements, there’s still another layer of decisions and understanding when it comes to reviewing and approving medical leave requests: how you want to handle medical certifications. The three main questions you need to answer (that we’ll guide you through) are:

1. Should you request employees complete a medical certification form? 
2. How closely will you scrutinize it? (And what are you scrutinizing for?)
3. When can/should you request more information than you initially receive? 

The risk of error and non-compliance can rise when managing this decision manually, in addition to being time-consuming. This guide breaks down the key decisions employers need to make about medical certification paperwork, with insights into how Cocoon can help you automate and document the process.

What is a Serious Health Condition (SHC) form?

Under FMLA, medical leave is granted only to those with a serious health condition (as defined by the law) that prevents them from working. Though a Serious Health Condition (SHC) form (aka Form WH 380E) is not legally required for FMLA compliance, many employers find it helpful to substantiate an employee’s need for medical leave under state leave laws and company medical leave policies. It asks for information that must be supplied for an FMLA medical leave regardless of the condition or nature of leave sought, like: contact information for the healthcare provider, dates the medical condition started or will start, an estimate of how long the condition will last, whether leave will be taken on a continuous or intermittent basis, and other pertinent facts to justify and provide insight into the likely duration of the leave. They might also include details about the type of care, treatment, care regimens, and conditions an employee is facing.

Should you require a medical certification form?

When evaluating and approving medical leaves, the first thing employers must decide is if they want to request/require a medical certification form to justify the need for leave. Though the SHC form itself is optional under FMLA, most employers tend to require some type of certification to proactively comply with other FMLA requirements, prevent leave abuse, and effectively manage the operational impact of an employee’s absence. Additionally, for some leaves that are eligible for short-term disability or state disability/leave benefits, the employee might be required to provide medical documentation similar to and potentially including the same information as an SHC form regardless to file claims for short term disability or state paid leave benefits.

The FMLA also does not require employees or employers to use any specific certification form—Form WH 380E or otherwise. If there are certain details your organization prefers to know, then you could create your own form for a healthcare provider to sign off on. Employers, however, cannot reject a medical certification that contains all the information needed to determine if the leave is FMLA-qualifying. For example, employers cannot refuse: 

• A fax or copy of the medical certification
• A medical certification that is not completed on the employer’s standard company form, or 
• Any other record of the medical documentation, such as a communication on the letterhead of the healthcare provider.

💡 Cocoon automatically tracks medical certification requests, the documents and information submitted for them, and stores them securely.

Issues that can arise when submitting medical certifications/SHC forms

If some sort of medical documentation is needed to support a leave request, you can almost guarantee that you’ll encounter some speed bumps.  Here are some of the more likely ones:

1. Forms don’t get submitted

If an employee simply never submits a medical certification form or refuses to do so, you can deny the leave. However, it may be worth discussing it further with the employee to find out if they simply need more time, their condition is preventing them from getting it done, or are concerned about revealing certain details of their condition. 

2. Forms aren’t submitted on time 

Once requested by an employer, an employee has 15 calendar days to submit medical certification forms. This is typically the case unless it’s simply not possible due to particular circumstances, despite an employee’s good faith effort to do so (if this is the case, the FMLA requires employers to extend this deadline.) To increase employee accountability and help reduce the risk of multiple extensions or leave abuse, you might consider asking an employee to explain (ideally in writing) what efforts they have taken to obtain the form, why they were unsuccessful, and when they expect to have it.

💡 Employees can submit medical certification and get notifications about deadlines to do so all in Cocoon. Cocoon also provides an automatic five-day grace period to help reduce potential operational friction arising from this exception. If no paperwork is submitted by day 21, the leave can be denied.

3. Forms are incomplete/insufficient

First, you must provide written notice to the employee that a form is incomplete or insufficient, explaining what data was missing, or what made it insufficient. From here, employees have seven calendar days to fix any issues. We’ll dive deeper into this issue in the last section of the blog.

💡 Cocoon can help you send and keep track of this correspondence and the updated certifications provided in the re-submission process. If more than seven days are needed, Cocoon can help you extend the deadline.

How closely will you review medical certifications?

Once successfully submitted, the next consideration is how thoroughly will you review the documentation? The level of scrutiny you choose to exercise may depend on the bandwidth of your People Ops team, the employee experience you’re aiming for, and your company culture and policies. Some approaches include:

Auto-approval

Once a completed form is submitted, it’s automatically approved regardless of the information in it. 

• Pros: fastest option, smoothest employee experience
• Cons: errors can slip through unnoticed, problems or questions might arise that could have been addressed sooner, approval of an unjustified leave 

Light touch

A form is reviewed quickly for completeness and generally approved unless there are clear issues. 

• Pros: balance ease with oversight, catch basic errors
• Cons: still might not catch problems or questions until later

Detailed review

People Ops reviews each form closely to ensure completeness, clarity, compliance, accuracy, and proactive planning.

• Pros: problems or questions immediately addressed, best for stricter absence management
• Cons: takes more HR bandwidth, requires familiarity in reviewing forms, employees might feel scrutinized

💡 You can review and approve forms directly from Cocoon with the level of depth you choose, from auto-approval to a full, detailed review.

What to look for when reviewing medical certification forms

So, your organization has decided to require medical certification forms, and doesn’t automatically approve a form upon submission… What information are you actually looking for on the forms?

1. Is the form complete and sufficient?

Here, you’re looking to make sure nothing was left blank, and that you have the needed information to qualify an employee for FMLA-protected leave. A form is considered incomplete if one or more entries haven’t been filled out. Sometimes all the information is there, but healthcare providers may put it in a different place, or have their own form. This can make reviews a bit more challenging.

A certification is considered insufficient when the form is complete, but the information is inconclusive, contradictory, or illegible. For example, an estimated leave range says “2-3 months” without specifying dates, or leave dates suggested by a doctor do not coincide with the leave dates requested (more on this below). 

As noted above, if forms are incomplete/insufficient, written notice must be provided that explains what’s missing or incorrect, and given an employee at least seven days to provide the information (or a time frame otherwise established in the written notice). If the follow-up information is never provided, or is not provided within a reasonable time frame, the leave may be denied.

💡When a form is marked insufficient or incomplete, Cocoon will prompt you to explain the deficiency, email that notice to an employee, and track the task and timeline for an employee to respond all directly in Cocoon.

2. Does the information establish that the employee has a qualified serious health condition?

The FMLA defines a ‘serious health condition' as “an illness, injury, impairment, or physical or mental condition that involves either inpatient care or continuing treatment by a healthcare provider, involving a period of incapacity that prevents them from being able to work.” Generally, there are six situations where an employee’s medical condition will qualify: 

1. They need inpatient care, getting admitted for an overnight stay in a hospital, hospice, or residential medical care facility.
2. They are/will be incapacitated and require treatment of more than three consecutive full calendar days (e.g., outpatient surgery, recovering from a major infection).
3. They are pregnant, and have medical conditions related to pregnancy or childbirth.
4. They have an ongoing chronic condition that requires two or more treatments on a regular basis or cause prolonged periods of illness (e.g., Crohn’s disease, migraines).
5. They have a permanent or long-term condition (e.g., cancer, dementia) that requires continuing supervision of a healthcare provider even if treatment isn’t actively administered.
6. They have a condition requiring multiple treatments (e.g., chemotherapy treatments, restorative surgeries).

When reviewing certifications, employers evaluate whether the information provided satisfies one or more of these six situations.

💡 Check out more specific of FMLA-qualifying conditions here. You can easily view the SHC form in Cocoon to ensure a healthcare provider has checked appropriate boxes or provided the information sufficient for you to conclude that the condition prompting the employee’s leave is indeed an FMLA-covered serious health condition. 

If the SHC form fails to indicate that they have an FMLA-qualifying condition, their leave may be denied. Employers cannot exercise independent judgment on this—they need to stick to what the form indicates, and what boxes are checked or not. In the case that an FMLA-protected leave is denied, an employee may still be eligible under your company’s leave policies, or for other leave accommodations. 

💡 Cocoon automatically sends required FMLA designation notices informing employees that their leave was denied because the FMLA does not apply to their request.

3. Are there leave date discrepancies?

Here, there are critical details you’ll want to pay attention to:

The leave period is unclear or imprecise

If a form says, “employee will need approximately 2-3 months of leave” what does that actually mean in practice? 60 or 90 business or calendar days? Beginning and ending upon which dates? 

The employee seeks more leave than the healthcare provider authorizes 

For example, if an employee is seeking leave from July 1-31, but the certification says leave is only needed from July 5-19, you could: 

1. Approve the full leave request (July 1-31).
2. Partially approve and send a deficiency notice telling the employee that they will need to provide an updated certification supporting the additional leave dates.
3. Only approve the leave dates the healthcare provider has authorized (July 5-19).

The employee seeks less leave than the healthcare provider authorizes 

Employers are prohibited from forcing employees to use more leave than they are seeking, but here you might want to partially approve and send a deficiency notice to determine what the employee wants. Essentially, the deficiency notice informs the employee of the leave date discrepancy and gives them an opportunity to update their leave request to match the healthcare provider’s certification. If the employee responds, approve the leave consistent with their wishes. If they don’t respond, then approve the leave for only the period of time originally requested. 

4. Does the request entail intermittent or reduced schedule leave?

If an employee requests leave on an intermittent or reduced schedule leave, the certification must establish the medical necessity for it, and provide a best estimate of the dates and duration of treatments. For conditions that might result in unforeseeable episodes of incapacity (e.g., flare-ups from chronic physical or mental serious health conditions like: back ailments, migraine headaches, depression, anxiety, asthma, pre- or post-natal medical complications), healthcare providers must estimate the frequency or duration of these episodes, with the understanding that they can change and need periodic revisions.

5. Forms are complete and sufficient, but you need further authentication or clarification

Sometimes a form has the required information, but still raises questions. An employer cannot contact a healthcare provider to request additional information, but an HR professional or leave administrator (not a manager or supervisor) can contact the healthcare provider to authenticate or clarify a certification. 

• Authentication is when you are confirming that the healthcare provider was the one who actually completed and authorized the form. Submit a copy of the certification in question and request the verification from the healthcare provider.
• Clarification is when you cannot understand what is written either because it’s illegible or needs further explanation. Submit a copy of the certification and ask the healthcare provider about the section(s) that need clarification. 

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule must be followed when personal health information of an employee is shared with an employer by a healthcare provider; an employee has to authorize the release of this information to you as their employer. Should an employee choose not to authorize its release, and they don’t otherwise clarify the certification, you may deny the FMLA leave if the certification remains unclear.

6. Do you want or need a second opinion? A third opinion?

If an employer still has reason to doubt the validity of a medical certification, they may require the employee to obtain a second option, but at the employer’s expense. An employer is able to designate the healthcare provider of their choice to provide the second opinion. 

However, the healthcare provider in question cannot: 

• Be employed on a regular basis by the employer
• Regularly contract with them the employer
• Have their services utilized regularly by the employer (except in areas where access to healthcare is extremely limited and only one or two specialists are in the vicinity).

In the event that the opinions of the employee and employer’s designated healthcare providers differ, the employer may require the employee to obtain certification from a third provider (again at the employer’s expense). The third opinion is final and binding. The third provider must be designated or jointly approved by the employer and employee, both of them acting in good faith to reach an agreement upon the third provider. If the employer does not attempt in good faith to reach agreement, the employer will be bound by the first certification. If the employee does not attempt in good faith to reach agreement, the employee will be bound by the second certification.

The bottom line

While this guide does its best to break down the medical certification form process and troubleshooting it, we know it can still be overwhelming for People Ops reviewing SHC forms, and for employees trying to submit them. That’s exactly why leave management software like Cocoon was created—to help you codify and document the policies, processes, deadlines, and submissions surrounding a medical leave request, for a smoother employee experience, with lighter work- and stress-loads for all. If you’re ready to see what this could look like for your organization, give it a whirl. If not, we’ll always be here with guides and checklists to help you through it.