Family Member's Certification of Health Care Provider

This form is to be completed by your covered family member's physician and submitted within 15 calendar days of your leave request form.  Your physician should fax the fully completed form to (313) 748-6119.  Leaves cannot be approved until a complete and sufficient Certification of Health Care Provider form has been received and reviewed.

Please note, a separate form is required for each covered family member, they should not be noted on the same form.

WH-380-F.pdf, 208.04 KB; (Last Modified on July 8, 2019)