Fill Out Form WH-380-E, Certification of Health Care Provider for Employee's Serious Health Condition (FMLA)
Stop struggling with medical certification forms when an employee needs FMLA leave. Upload your WH‑380‑E PDF, answer clear questions about employer details and medical facts, and Simplicity AI fills every required field accurately. Review and export a complete form ready to return to HR.
AI converts the WH-380-E into an interactive form. No manually tapping into dense medical certification fields or deciphering DOL formatting.
Upload prior medical records or a doctor's summary as a source document, and Simplicity AI pulls diagnosis details, treatment dates, and provider information into the correct sections.
Intermittent leave, reduced schedule, or continuous absence? AI prompts are displayed in the specific fields that apply to your leave type, so nothing required is left blank.
Form INFORMATIONS
Section I — Employee Information:
Employee name (full legal name, matching HR records), employer name (company or organization; use name on pay stubs if DBA applies), employee job title (current position—Section IV assesses ability to perform essential functions), and a brief job description including physical requirements, mental demands, and working conditions. Your healthcare provider uses this to determine whether the condition prevents you from performing your specific role. Simplicity AI prompts for targeted details so the description supports an accurate medical assessment.
Section II — Health Care Provider Information:
Provider name (physician, surgeon, psychologist, podiatrist, dentist, optometrist, chiropractor, NP, nurse midwife, clinical social worker, or PA as applicable), type of practice or medical specialty, address, phone, and fax. HR may contact the provider for clarification only through HR, benefits manager, or the employer's healthcare provider—not your direct supervisor. Simplicity AI lists qualifying provider types so the right person completes the form.
Section III — Condition and Treatment Details:
Date condition commenced (approximate onset); probable duration (or chronic/indefinite with next reevaluation date); diagnosis (ICD code if available); brief statement of treatment (medications, therapies, procedures, referrals); whether inpatient hospitalization is or was required (dates if yes); whether the employee is presently incapacitated (unable to perform at least one essential job function). These establish that the condition meets FMLA's "serious health condition" definition.
Section IV — Fitness for Duty and Work Capacity:
Whether the employee is unable to perform any job functions (and which ones, based on the Section I job description). Leave type: Continuous (single uninterrupted block—e.g., surgery recovery); Intermittent (periodic absences—frequency and duration of episodes, e.g., migraines, Crohn's, chemotherapy); Reduced schedule (fewer hours or days per week—estimated hours/days and duration). The provider selects the type that matches the condition and treatment. Simplicity AI shows only the fields that apply to the selected leave type.
Section V — Signature:
The treating healthcare provider listed in Section II must sign, certifying the information is true and complete. Not office staff or another provider in the practice. Date of signature. The employee has 15 calendar days from the employer's request to return the completed form; request an extension before the deadline if the provider needs more time. Representative information if an authorized person is filing on the employee's behalf.
WHAT IS FORM WH-380-E?
What Is Form WH-380-E and Who Needs to Fill It Out?
Form WH-380-E, officially called "Certification of Health Care Provider for Employee's Serious Health Condition," is how your healthcare provider medically certifies that you have a condition qualifying for protected leave under the Family and Medical Leave Act (FMLA). It isn't filed with a government agency. Instead, your employer keeps it on file as the legal basis for approving your FMLA leave, holding your job, and maintaining your health insurance while you're away.
You likely need a WH-380-E if: you have a serious health condition requiring inpatient care, surgery, or extended recovery; you manage a chronic condition (e.g., migraines, Crohn's, epilepsy, lupus, PTSD) that causes periodic absences; you're in a course of treatment (chemotherapy, dialysis, radiation, physical therapy) requiring time away; you need a reduced schedule because your condition or treatment prevents full hours; or your employer is requesting recertification to extend or continue FMLA protection.
The form is four pages, but medical terminology, leave type distinctions (continuous vs. intermittent vs. reduced schedule), fitness-for-duty assessments, and the 15-day return deadline often trip people up. Simplicity AI guides you through each section and ensures the right leave type and fields are completed.
How to Fill Out Your WH-380-E Online in 6 Simple Steps
1
Upload your WH-380-E PDF to Simplicity AI. The AI scans all five sections and converts the form into a guided, interactive questionnaire.
2
Enter the employee's name, employer name, job title, and a brief description of essential job functions. If your employer attached a separate job description, upload it as a source document.
3
Enter the healthcare provider's name, medical specialty, address, phone, and fax number. Provider details can carry over if you've used Simplicity AI before.
4
Complete the medical certification: date condition commenced, diagnosis, treatment plan, hospitalization status, and whether the employee is presently incapacitated.
5
Select the leave type needed: continuous, intermittent, or reduced schedule. AI prompts for the specific fields that apply, including frequency, duration, and estimated work capacity.
6
Review every section for accuracy, have the healthcare provider sign electronically, and download your completed WH-380-E as a clean PDF ready to return to the employer.
Super Fast
Complete your WH-380-E in minutes. No deciphering dense DOL formatting or flipping between five sections to figure out which leave type fields apply.
AI-Powered
Simplicity AI understands the WH-380-E structure, from employee information through fitness-for-duty assessment. It matches your leave type to the correct fields so nothing required is left blank.
Secure
Your WH-380-E contains sensitive data, including medical diagnoses, treatment plans, hospitalization records, and work capacity assessments. Documents are encrypted, handled privately, and never shared. Your data stays yours.
FAQs
Frequently Asked Questions About Form WH-380-E
What is Form WH-380-E, and why do I need to fill it out?
Form WH-380-E is the Department of Labor's official medical certification form for FMLA leave. Your employer requires it to verify that you have a serious health condition that qualifies for protected leave. Without a completed WH-380-E, your employer can delay or deny your FMLA leave, meaning they're not legally required to hold your job or maintain your health insurance while you're away.
How do I fill out Form WH-380-E online for free?
You can fill out Form WH-380-E online for free using Simplicity AI. Our platform converts the PDF into a guided questionnaire that walks you through each section, from employee information to the healthcare provider's medical certification. Upload your WH-380-E PDF and follow the prompts to complete your form in minutes.
Who fills out the WH-380-E, the employee or the doctor?
Both. The employee completes Section I (name, employer, job title, and job description). The healthcare provider completes Sections II through V (provider information, medical condition details, leave type and duration, and signature). Simplicity AI separates the employee and provider sections so each person only sees the fields they're responsible for.
What counts as a "serious health condition" under FMLA?
A serious health condition is an illness, injury, impairment, or physical or mental condition that involves either inpatient care (an overnight hospital stay) or continuing treatment by a healthcare provider. This includes chronic conditions requiring periodic treatment, long-term conditions requiring supervision, and conditions requiring multiple treatments such as chemotherapy, dialysis, or physical therapy. A common cold or flu generally doesn't qualify unless complications arise.
How long do I have to return the completed WH-380-E to my employer?
You have 15 calendar days from the date your employer requests the certification. If your healthcare provider can't complete it within that window, notify your employer before the deadline and request an extension. Failing to return the form on time gives your employer grounds to delay or deny your FMLA-protected leave.
Can my employer contact my doctor directly about my WH-380-E?
Your direct supervisor cannot contact your healthcare provider. However, your employer's HR department, benefits manager, or the company's own healthcare provider can contact your doctor for clarification or authentication of the certification. They can only ask about information already on the form; they cannot request additional medical records or a diagnosis beyond what the WH-380-E requires.
What's the difference between continuous, intermittent, and reduced schedule leave?
Continuous leave is a single, uninterrupted block of time away from work (e.g., six weeks for surgery and recovery). Intermittent leave is periodic absences due to the same condition (e.g., two days per month for chemotherapy). Reduced schedule leave means working fewer hours per day or fewer days per week (e.g., four hours instead of eight during radiation). Your healthcare provider selects the appropriate type on the WH-380-E based on your condition and treatment plan.
Is my data safe when filling out Form WH-380-E on Simplicity AI?
Yes. Your WH-380-E contains sensitive medical information, including diagnoses, treatment plans, hospitalization records, and work capacity assessments. Simplicity AI encrypts all documents, handles your data privately, and never shares it with third parties. Your data stays yours.
Common Mistakes in Completing Form WH-380-E
Vague or Missing Job Description in Section I
Your healthcare provider can't assess whether you can perform your job functions without knowing what your job requires. "Office work" or "general duties" gives the provider nothing to work with and gives your employer grounds to request a second opinion or reject the certification. Be specific: lifting, hours on your feet, cognitive demands, travel. Simplicity AI prompts you with targeted questions so the description is detailed enough for an accurate medical assessment.
Submitting a Doctor's Note Instead of the Actual Form
A letter from your physician saying "Patient needs time off" does not satisfy the FMLA certification requirement. Your employer can reject it and require the WH-380-E. The WH-380-E is the specific DOL form that triggers FMLA's legal protections. Simplicity AI converts the WH-380-E into a guided questionnaire so you complete the right form from the start.
Selecting the Wrong Leave Type
Continuous, intermittent, and reduced-schedule leave each require different fields. Checking "continuous" when you need periodic absences means your employer approves a single block of leave; when you have a flare-up later and miss a day, that absence isn't covered. Simplicity AI explains each leave type in plain English and shows only the fields that match your selection.
Missing the 15-Day Return Deadline
You have 15 calendar days to return the completed form. If you miss the deadline without requesting an extension, your employer can delay or deny your FMLA leave. If your doctor needs more time, notify your employer before the 15-day period expires. Simplicity AI helps you complete the employee sections quickly so the main variable is your provider's schedule.
Leaving Medical Fields Incomplete
Every blank field in Sections III and IV is a reason for your employer to request clarification or reject the certification. Missing the date the condition commenced, probable duration, or a vague treatment plan leads to back-and-forth and delayed leave approval. Simplicity AI flags required fields before you export the form.
Provider Signs but Doesn't Specify Frequency or Duration for Intermittent Leave
If your provider checks "intermittent leave" but doesn't estimate how often episodes occur or how long each lasts, your employer has no basis for approving the schedule and will send the form back. Your provider needs specifics (e.g., "Episodes occur approximately 2-3 times per month, lasting 1-2 days each"). Simplicity AI prompts for frequency and duration whenever intermittent leave is selected.
Wrong Provider Completing the Form
Not every healthcare professional qualifies to certify FMLA leave. The provider must be a physician, surgeon, clinical psychologist, podiatrist, dentist, optometrist, chiropractor (for manual manipulation only), nurse practitioner, nurse midwife, clinical social worker, or physician assistant authorized in your state. If your massage therapist, acupuncturist, or unlicensed counselor signs, your employer can reject it. Simplicity AI lists qualifying provider types in Section II.
Not Keeping a Copy for Your Records
Once you return the WH-380-E to your employer, the original stays in their files. If a dispute arises later about what was certified or what leave was approved, you need your own copy. Simplicity AI exports a clean PDF you can download and save before submitting the original to your employer.
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