Certification Of Health Care Provider For Family Members Serious Health Condition {WH-380-F}

SECTION I: For Completion by the EMPLOYER INSTRUCTIONS to the EMPLOYER:SECTION II: For Completion by the EMPLOYEE INSTRUCTIONS to the EMPLOYEE:003003 American LegalNet, Inc. www.FormsWorkFlow.com SECTION III: For Completion by the HEALTH CARE PROVIDER INSTRUCTIONS to the HEALTH CARE PROVIDER: 002002002002002003 003 American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com 002002002002 002Signature of Health Care Provider Date PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT. American LegalNet, Inc. www.FormsWorkFlow.com