1. (1) name, address, telephone number, email address (if available), license number and state of license of the health care provider, and the type of medical practice/specialization;
2. (2) approximate date on which the serious health condition commenced, and its probable duration;
3. (3) certification regarding the patient’s health condition for which PFL is requested. The certification must be sufficient to support the need for leave; and
4. (4) an estimate of the frequency and duration of the leave required to care for the family member, including whether the need for care is continuing or on an intermittent basis.
5. (b) A health care provider may refuse to supply a certification for family leave when the employee requesting the leave is the perpetrator of domestic violence or child abuse against the care recipient.
6. (c) In all instances in which certification is required, it is the employee’s responsibility to provide the carrier with a complete and sufficient certification, and failure to do so may result in the denial of family leave. The authorization, release, or waiver executed by the care recipient shall be subject to the authorization rules and exceptions thereto of the HIPAA Privacy Rule (45 C.F.R. parts 160 and 164 [2005]).

(a) Required information.

When leave is taken because of the serious health condition of a family member, the employee must obtain a medical certification from a health care provider that sets forth the following information: