HOW TO REQUEST PAID FAMILY LEAVE

to care for a family member with a serious health condition

BEFORE YOU APPLY FOR PAID FAMILY LEAVE

■ Check the eligibility requirements. See next page or visit PaidFamilyLeave.ny.gov/eligibility.

■ Plan your leave. Leave can be taken all at once or intermittently, but must be taken in full-day increments.

■ Notify your employer at least 30 days in advance, if foreseeable, or as soon as possible.

COMPLETE YOUR FORMS AND ATTACH REQUIRED DOCUMENTATION

Complete the Request for Paid Family Leave (Form PFL-1).
Note: This form has sections that need to be completed by you and by your employer.

■ 


Fill out your section, make a copy, and give the form to your employer to fill out Part B.
Your employer is required to return Form PFL-1 to you within three business days. If there is a delay,
you do not have to wait to proceed. Send the Form PFL-1 that you have filled out, along with the rest
of your request package, directly to your employer's insurance carrier.

Complete the Release of Personal Health Information Under the Paid Family Leave Law (Form PFL-3).
 Your family member (the care recipient) completes Form PFL-3 and submits the form to their health

■ care provider to keep on file.

This form authorizes a health care provider to release information regarding your family member’s
serious health condition to you and your employer’s insurance carrier.
Do not send this form to the insurance carrier.

Complete the Health Care Provider Certification for Care of Family Member with Serious Health
Condition (Form PFL-4).

■ Note: This form has sections that need to be completed by the health care provider.
 Fill out your section, make a copy, and give the form to your family member’s health care provider.
 Ask the provider to complete their portion of the form and return it to you in a timely manner.

SUBMIT TO YOUR EMPLOYER’S INSURANCE CARRIER

You must submit your Mail or fax your Form PFL-1 and Form PFL-4 to your employer’s insurance carrier.
completed request To find out who your employer’s insurance carrier is, you can:
package to your ■ Look for the Paid Family Leave poster in your workplace.
employer’s insurance
■ Ask your employer.

■
carrier within 30 days
after the start of your ■ Look it up using the employer coverage search application on wcb.ny.gov.
leave to avoid losing If you cannot find your employer’s insurance carrier, call the Paid Family Leave
benefits. (PFL) Helpline for assistance: (844) 337-6303
Keep a copy of all forms The PFL Helpline is available Monday - Friday, 8:30 a.m. to 4:30 p.m.
and documentation for Please do NOT submit your request package to the NYS Workers’
your records. Compensation Board.

It is YOUR responsibility to submit the forms to the insurance carrier. It is NOT your employer’s responsibility.

PAIDFAMILYLEAVE.NY.GOV 1
 PAID FAMILY LEAVE TO CARE FOR A FAMILY MEMBER WITH A SERIOUS HEALTH CONDITION

Important to know
 In most cases, the insurance carrier must pay or deny benefits within 18 days of receiving your completed
request or your first day of leave, whichever is later. Your request cannot be considered incomplete solely
because your employer did not fill out Part B of Form PFL-1 within three business days.
 If the carrier denies or fails to timely pay your benefits, or you have any other claim-related dispute, you may
request to have the carrier’s actions reviewed. More information can be found at nyspfla.namadr.com.
  omplaints about employer discrimination or retaliation are resolved by a Workers’ Compensation Board Law
C
Judge after a hearing. If you believe that your employer has discriminated or retaliated against you for taking
or requesting Paid Family Leave, visit PaidFamilyLeave.ny.gov/protections or contact (844) 337-6303.

Eligibility FAMILY MEMBERS YOU CAN CARE FOR:

  ost employees who work for private employers in New York
M Spouse/domestic partner
State are covered under Paid Family Leave. Child/stepchild
■ Full-time employees: If you work a regular Parent/stepparent/parent-in-law
schedule of 20 or more hours per week, you are
eligible after 26 consecutive weeks of employment Grandparent
with your employer. Grandchild
■ Part-time employees: If you work a regular Sibling (New in 2023!) Check with your
schedule of less than 20 hours per week, you are employer’s insurance carrier for details on
eligible after working for your employer for 175 when this goes into effect for their policy.
days, which do not need to be consecutive.
CARE CAN INCLUDE PROVIDING:
  on-represented public employees may be covered if their
N
employer has voluntarily opted in to provide the benefit. Necessary physical care
Union-represented public employees may be covered if the Emotional support
benefit has been negotiated through collective bargaining.
Visitation
  itizenship and/or immigration status is not a factor in
C Assistance in treatment
employee eligibility.
Transportation
 If you believe you are eligible, you can apply for Paid Family
Help arranging for a change in care
Leave and the insurance carrier will make a determination.
Assistance with essential daily activities
 If you have questions about eligibility rules, call the PFL Helpline
at (844) 337-6303 (Monday - Friday, 8:30 a.m. to 4:30 p.m.). Personal attendant services

Remember: It is YOUR responsibility to submit the forms to the insurance carrier. It is not your employer’s responsibility.

For more information, visit PaidFamilyLeave.ny.gov or call (844) 337-6303.

2
PFL-Form-FamilyCare-Cover-v2 11-22
Request for Paid Family Leave (Form PFL-1) Instructions
• To request Paid Family Leave (PFL), the employee requesting PFL must complete Part A of the Request for Paid Family
Leave (Form PFL-1). 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 business 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.

PART A - EMPLOYEE INFORMATION (to be completed by the employee)

The employee requesting PFL must complete all required information.

PFL Request (to be completed by the employee)

Question 12: A child includes a biological, adopted, indicate “Dates are estimated.”
or fostered child, a stepchild, a legal ward, a child of a
If dates are estimated, the PFL carrier may require you to
domestic partner, or the person to whom the employee
submit a request for payment after the PFL day is taken.
stands in loco parentis. A parent is defined as a biological, Payment for approved claims will be due as soon as
foster, or adoptive parent, parent-in-law, a stepparent, a possible but in no event more than 18 days from the date of
legal guardian, or other person who stood in loco parentis the completed request.
to the employee when the employee was a child.
Question 14: If the employee is submitting the PFL
Question 13: If dates are “Continuous,” the employee request to their employer with less than 30 days’ advance
must provide the start and end dates of the requested PFL. notice from the start date of the PFL, the employee must
These dates should be the actual dates that the PFL will explain why 30 days’ notice could not be given. If the
begin and end. If uncertain, estimate the start and end explanation will not fit in the space provided on the form,
dates and indicate “Dates are estimated.” If dates are enter “See attached” and add an attachment with the
“Periodic,” enter the dates PFL will be taken. Please be as explanation. Be sure to include the employee’s full name
specific as possible. If the dates are unknown or estimated, and their date of birth at the top of the attachment.

Employment Information (to be completed by the employee)

Question 16: Enter the date of hire to the best of the the prorated weekly amount to the average weekly wage.
employee’s recollection. If it has been more than a To determine the prorated weekly amount, add all
year since the date of hire, entering the year in which bonuses/commissions earned in the preceding 52 weeks
employment started is sufficient. and then divide by 52.
Question 18: Enter the best estimate of average gross Example of a gross weekly wage calculation:
weekly wage. Include only the wages earned from the Week 1 - Gross wage including overtime $550
employer listed on this request form. The gross weekly Week 2 - Gross wage $500
wage is the total weekly pay — including overtime, tips, Week 3 - Gross wage $500
bonuses and commissions — before any deductions are Week 4 - Gross wage $500
made by the employer, such as federal and state taxes. If Week 5 - Gross wage $500
the employer is not able to supply this information, the Week 6 - Gross wage $500
employee can calculate their gross weekly wage as follows: Week 7 - Gross wage, including overtime $600
Step 1: Add all gross wages received (before any Week 8 - Gross wage, including overtime + $550
deductions) over the last eight weeks prior to the start of Total = $4,200
PFL, including overtime and tips earned. (See Step 3 for Divide by 8 ÷ 8
instructions for calculating bonuses and/or commissions.)
Average Weekly Wage = $525
Step 2: Divide the gross wages calculated in step one by
eight (or the number of weeks worked if less than eight) Bonus earned in preceding 52 weeks $2,600
to calculate the average weekly wage. Divide by 52 ÷ 52
Step 3: If the employee received bonuses and/or Prorated Weekly Bonus = $50
commissions during the 52 weeks preceding PFL, add Form PFL-1 Instructions continued on next page

Form PFL-1 Instructions If you need assistance, please call (844) 337-6303
Page 1 of 2 paidfamilyleave.ny.gov DO NOT SCAN
FORM PFL-1 INSTRUCTIONS - CONTINUED FROM PRIOR PAGE

PART A - EMPLOYEE INFORMATION (to be completed by the employee) - continued from prior page
Form PFL-1 Instructions continued from prior page or self-insured employer, the missing information must
be supplied as soon as it is known. Benefits cannot be
Average Weekly Wage $525
determined until all of the required information is provided.
Prorated Weekly Bonus + $50
The PFL insurance carrier or self-insured employer will
Average Weekly Wage (including bonus) = $575 provide the employee a notice within five days which 1)
Please note that the employer is also required to provide states the claim is pending; 2) identifies what information is
this information in Part B of the Request for Paid Family missing; 3) instructs how to submit the missing information.
Leave (Form PFL-1). Once all information is supplied, the PFL insurance
carrier or self-insured employer has 18 days to pay or
When pre-submitting form: Indicate if the employee is deny the claim.
pre-submitting their PFL request. Pre-submitting is defined If the carrier or self-insured employer does not permit pre-
as submitting the application in advance of an upcoming submitting, the carrier or self-insured employer must return
qualifying event, with certain required information missing the Request for Paid Family Leave to the employee within
due to the information being unknown at the time of the five days explaining that the claim should be re-submitted
submission. If pre-submitting is permitted by the carrier when all information is available.
Employee signs and dates before giving this form to their employer to complete Part B.

PART B - EMPLOYER INFORMATION (to be completed by the employer)

The employer of the employee requesting PFL must complete all information in Part B.
Question 2: If a Social Security number is used for the Question 10: Failure to select “Yes” for requesting
Federal Employer Identification Number (FEIN), enter the reimbursement from the insurance carrier will result in a
Social Security number. waiver of the right to reimbursement.
Question 3: Enter the employer’s Standard Industrial Question 11a: ‘Disability’ refers to NYS statutory required
Classification (SIC) Code. Employers should contact their disability. If the answer is “none,” enter a “0” for total weeks
carrier if they don’t know their SIC code. and days in Question 11b.
Question 8: The employee occupation code can be found
at: www.bls.gov/soc/2018/major_groups.htm Question 11b: The maximum number of weeks available
for NYS statutory disability and PFL in any 52-week period
Question 9: Enter the wages earned by the employee
is 26 weeks. Specify the total number of weeks, as well as
during the last eight weeks preceding the PFL start date.
the number of additional days if the leave includes a partial
The gross amount paid is the employee’s gross weekly
week, taken for NYS statutory disability and PFL during the
pay, including any overtime and tips earned for that
preceding 52 weeks.
week, plus the weekly prorated amount of any bonus or
commission received during the preceding 52 weeks. (For Questions 13, 14 & 15: Enter the Paid Family Leave or
detailed steps, see Question 18 starting on page 1 of the Disability/PFL insurance carrier’s name, address and PFL
instructions.) Calculate the gross average weekly wage by policy number. If this employer is self-insured, enter the
adding up the gross amounts paid, and then dividing the name and address of where the PFL request should be
total by eight (or number of weeks worked if less than eight). submitted for processing.
Affirmation 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.
Employer signs and dates, and then returns to the employee requesting PFL within three business days.

Be sure to complete the appropriate additional PFL form(s)

based on the type of leave being requested.

Notification Pursuant to the New York Personal Privacy Protection Law (Public Officers 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 Taxpayer
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 Taxpayer 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.

Form PFL-1 Instructions If you need assistance, please call (844) 337-6303
Page 2 of 2 paidfamilyleave.ny.gov
 Request for Paid Family Leave
(Form PFL-1)
INSTRUCTIONS INCLUDED WITH FORM
PART A - EMPLOYEE INFORMATION (to be completed by the employee)

1. Employee’s legal name (first name, middle initial, last name)

Syed Mohammed Baki Optional (for research purposes)

10. Employee’s ethnicity/race

2. Other last names, if any, under which employee has worked 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?

3. Employee’s mailing address
(One or more categories may be selected.)
Street address
Mexican
Mexican American
City, State
Chicano/a
Puerto Rican
Zip code Country (if not U.S.A.) Dominican
Cuban
Another Hispanic, Latino/a, or Spanish origin
4. Employee’s Social Security number or Taxpayer Identification Number
Not of Hispanic, Latino/a, or Spanish origin
- -
Unknown

5. Employee’s date of birth (MM/DD/YYYY) What is employee’s race?

(One or more categories may be selected.)
/ /
American Indian or Alaska Native
6. Employee’s primary telephone number Black or African American
( ) - Asian Indian
Chinese
7. Employee’s preferred email address while on PFL (if available) Filipino
Japanese
Korean
8. Employee’s gender
Vietnamese
M F X
Other Asian

9. Employee’s preferred language White

English Español Русский Polski Native Hawaiian

中文 Italiano Kreyòl ayisyen 한국어 Guamanian or Chamorro

Other Samoan
Other Pacific Islander
Other race

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 Sibling

Form PFL-1 continued on next page

PFL-1 (12-22) If you need assistance, please call (844) 337-6303

Page 1 of 4 paidfamilyleave.ny.gov PFL-1 12-22
FORM PFL-1 - CONTINUED FROM PRIOR PAGE

TO BE COMPLETED BY THE EMPLOYEE

Employee’s name (first name, middle initial, last name) Employee’s date of birth (MM/DD/YYYY)
Syed Mohammed Baki / /

PART A - EMPLOYEE INFORMATION (to be completed by the employee) - continued from prior page
Form PFL-1 continued from prior page
13. Will PFL be for a continuous period of time and/or intermittent?

PFL start date (MM/DD/YYYY) PFL end date (MM/DD/YYYY)

Continuous Dates are estimated
/ / / /

Identify dates intermittent PFL will be taken: Dates are estimated

Intermittent

14. If providing less than 30 days’ advance notice to the employer, please explain:

Employment Information (to be completed by the employee)

15. Business name

16. Employee’s date of hire (MM/DD/YYYY) / /

17. Employee’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 benefits? Yes No

Disclosure statement: Information regarding PFL benefits received by the employee, such as payments received and types of leave, will be provided to the employer.

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.

PFL-1 (12-22) If you need assistance, please call (844) 337-6303

Page 2 of 4 paidfamilyleave.ny.gov
FORM PFL-1 - CONTINUED FROM PRIOR PAGE

TO BE COMPLETED BY THE EMPLOYEE

Employee’s name (first name, middle initial, last name) Employee’s date of birth (MM/DD/YYYY)
Syed Mohammed Baki / /

PART B - EMPLOYER INFORMATION (to be completed by the employer)

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 Classification (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/2018/major_groups.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

Calculated average gross weekly wage:

10. If employee received or will receive full wages while on PFL, will employer be requesting reimbursement? Yes No
Form PFL-1 continued on next page

PFL-1 (12-22) If you need assistance, please call (844) 337-6303

Page 3 of 4 paidfamilyleave.ny.gov
FORM PFL-1 - CONTINUED FROM PRIOR PAGE

TO BE COMPLETED BY THE EMPLOYEE

Employee’s name (first name, middle initial, last name) Employee’s date of birth (MM/DD/YYYY)
Syed Mohammed Baki / /

PART B - EMPLOYER INFORMATION (to be completed by the employer) - continued from prior page

Form PFL-1 continued from prior 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:
Weeks Please provide specific dates for Disability:

Disability:
Days

Weeks Please provide specific dates for PFL:

PFL:
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

Declaration and signature

I affirm 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

PFL-1 (12-22) If you need assistance, please call (844) 337-6303

Page 4 of 4 paidfamilyleave.ny.gov
Release of Personal Health Information Under
the Paid Family Leave Law (Form PFL-3) Instructions
• If an employee is requesting Paid Family Leave (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
Certification 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 Certification for Care of Family Member with Serious Health Condition (Form
PFL-4) and release it to the employee seeking PFL benefits.
• 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 Certification 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 benefit 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.

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 Certification for Care of Family Member with Serious Health Condition (Form PFL-4).

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)

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 identified 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 fill 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.

Notification Pursuant to the New York Personal Privacy Protection Law (Public Officers 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 Taxpayer
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 Taxpayer 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.

Form PFL-3 Instructions If you need assistance, please call (844) 337-6303
Page 1 of 1 paidfamilyleave.ny.gov DO NOT SCAN
 Request for Paid Family Leave
Release of Personal Health Information
Under the Paid Family Leave Law (Form PFL-3)
INSTRUCTIONS INCLUDED WITH FORM

TO BE COMPLETED BY THE EMPLOYEE

Employee’s name (first name, middle initial, last name)
Syed Mohammed Baki

Care recipient’s (patient’s) name (first name, middle initial, last name) Care recipient’s (patient’s) date of birth (MM/DD/YYYY)
Syeda Hasme Ara Begum 0 6 / 2 5 / 1 9 3 7

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’s (patient’s) name

I, Syeda Hasme Ara Begum , authorize my health care provider listed on this form to
Employee’s name

release my personal health information to Syed Mohammed Baki and their

PFL insurance carrier’s name

employer's PFL insurance carrier .

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 certification. 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 benefits.

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 specifically 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 benefits.
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

PFL-3 (12-22) Release of PHI If you need assistance, please call (844) 337-6303
Page 1 of 2 paidfamilyleave.ny.gov PFL-3 12-22
FORM PFL-3 - CONTINUED FROM PRIOR PAGE

TO BE COMPLETED BY THE EMPLOYEE

Employee’s name (first name, middle initial, last name)
Syed Mohammed Baki

Care recipient’s (patient’s) name (first name, middle initial, last name) Care recipient’s (patient’s) date of birth (MM/DD/YYYY)
Syeda Hasme Ara Begum 0 6 / 2 5 / 1 9 3 7

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

Care Recipient Information (to be completed by the care recipient or authorized representative)

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 Certification for Care of Family Member
with Serious Health Condition (Form PFL-4) to the employee identified 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 benefits as a result of my current condition.

Care recipient’s signature

Date signed (MM/DD/YYYY)
/ /

Authorized representative
Print name

I, , 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 (12-22) Release of PHI If you need assistance, please call (844) 337-6303
Page 2 of 2 paidfamilyleave.ny.gov
Health Care Provider Certification for Care of Family Member
with Serious Health Condition (Form PFL-4) Instructions
The employee requesting Paid Family Leave (PFL) to care for a family member with a serious health condition must submit
the Health Care Provider Certification 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 number
or Taxpayer Identification Number (TIN), 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 Certification 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 identified above)

The patient’s health care provider must complete all applicable requested information unless noted as optional.
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 Certification 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 certification.

Employee:

• When you receive the completed Health Care Provider Certification for Care of Family Member with Serious Health
Condition (Form PFL-4) from the health care provider, send the completed forms and supporting documentation to the
insurance carrier.

Notification Pursuant to the New York Personal Privacy Protection Law (Public Officers 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 Taxpayer
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 Taxpayer 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.

Form PFL-4 Instructions If you need assistance, please call (844) 337-6303
Page 1 of 1 paidfamilyleave.ny.gov DO NOT SCAN
 Request for Paid Family Leave
Health Care Provider Certification for Care of Family
Member with Serious Health Condition (Form PFL-4)
INSTRUCTIONS INCLUDED WITH FORM

TO BE COMPLETED BY THE EMPLOYEE

Employee’s name (first name, middle initial, last name) Employee’s date of birth (MM/DD/YYYY)
Syed Mohammed Baki / /

Other last names, if any, under which employee has worked Employee’s Social Security number or TIN
- -

Employee’s mailing address

Mailing address

City, State Zip code Country (if not U.S.A.)

Care recipient’s (patient’s) name (first name, middle initial, last name) Care recipient’s (patient’s) date of birth (MM/DD/YYYY)
Syeda Hasme Ara Begum 0 6 / 2 5 / 1 9 3 7

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 identified above)

Care Recipient (Patient) Information (to be completed by the health care provider)

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 Days/month
OR

Health Care Provider Information (to be completed by the health care provider)

8. Health care provider’s name

Dr. Mahmuda khatun

Form PFL-4 continued on next page

PFL-4 (12-22) HCP Certification If you need assistance, please call (844) 337-6303
Page 1 of 2 paidfamilyleave.ny.gov PFL-4 12-22
FORM PFL-4 - CONTINUED FROM PRIOR PAGE

TO BE COMPLETED BY THE EMPLOYEE

Employee’s name (first name, middle initial, last name) Employee’s date of birth (MM/DD/YYYY)
Syed Mohammed Baki / /

Care recipient’s (patient’s) name (first name, middle initial, last name) Care recipient’s (patient’s) date of birth (MM/DD/YYYY)
Syeda Hasme Ara Begum 0 6 / 2 5 / 1 9 3 7

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 identified above)
- continued from prior page

Form PFL-4 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 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
City Digital Lab
City, State Zip code Country (if not U.S.A.)
Hospital Road, Moksudpur, Gopalgonj Bangladesh

11. Health care provider’s telephone number (provide area or country code) 08801842150194

12. Health care provider’s fax number (provide area or country code)

13. Health care provider’s email address (if available) citydigitallab.bd@gmail.com

14. State or country (if not U.S.A.) in which health care provider is licensed to practice Bangladesh

15. Specialty Obs & Gynae

16. Health care provider’s license number BMDC A-35793

Certification 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.
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)

/ /

PFL-4 (12-22) HCP Certification If you need assistance, please call (844) 337-6303
Page 2 of 2 paidfamilyleave.ny.gov