NY Paid Family Leave (PFL)

Claim Forms & Process

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Paid Family Leave (PFL) -  Claim Forms & Process

When an employee has a foreseeable situation, they should provide their employer 30 days advance notice of their intention to use Paid Family Leave. If the event was not foreseeable, the employee must notify their employer as soon as practical.

1) An employee should submit a completed claim package to their employer’s Paid Family Leave insurance carrier within 30 days of their
first day of paid leave. The insurance carrier must process the claim and issue a determination within 18 days.

2) A claim form will be available from an employer, the employer’s Paid Family Leave insurance carrier, or on the Paid Family Leave
website. Employers are also responsible for providing insurers with the dates that employees use Paid Family Leave.

Bonding With Child Forms to be Completed With Carrier Certification Required In Addition to Claim Forms

Birth Mother Filing

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Form PFL 1: Request PFL Benefits

• Part A: Employee To Complete
• Part B: Employer To Complete


Form PFL 2: Bonding Certification

Employee To Complete

The Birth Mother must submit:
1) A Birth Certificate, if available, or
2) Documentation of pregnancy, or
3) Documentation of Birth from a Health Care Provider

Note: The Document to include: Mother’s Name and Child’s Due Date or Birth Date

Other Parent Filing

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Form PFL 1: Request PFL Benefits

• Part A: Employee To Complete
• Part B: Employer To Complete


Form PFL 2: Bonding Certification

                            Employee To Complete

The Second Parent must submit, if available;
  1)    A Birth Certificate Naming Them as a Parent, If this is Not Available,
  2)    The Second Parent May Submit; A Voluntary Acknowledgment of Paternity or
         A Court Order of Filiation Naming Them as a Parent
 If those Documents are Not Available, the Second Parent Can Submit:
   1)   Birth Documentation From the Birth Mother’s Health Care Provider and
          a)    Either a Marriage Certificate or Evidence of a Civil Union or
          b)    Domestic Partnership to Demonstrate the Relationship to the Birth Mother

Foster Family Filing

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Form PFL 1: Request PFL Benefits

• Part A: Employee To Complete
• Part B: Employer To Complete


Form PFL 2: Bonding Certification

Employee To Complete

A Claim for Paid Family Leave to Bond with a Fostered Child Requires;
  1)    The Submission of a Letter of Placement Issued By a County or City Department of
         Social Services or Local Voluntary Agency.  
If a Second Parent is Not Named in Documentation;
  1)    A Copy of the Document Plus a Document Verifying the Relation to the Parent
         Named in the Foster Care Placement Will Be Needed

Adoptive Parent Filing

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Form PFL 1: Request PFL Benefits

• Part A: Employee To Complete
• Part B: Employer To Complete


Form PFL 2: Bonding Certification

Employee To Complete

A Claim for Paid Family Leave to Bond with an Adopted Child Requires:
  1)    A Court Document Finalizing Adoption, or Paid Family Leave Taken before the
         Adoption is Complete, a Document Showing the Adoption Process is Underway.
2) Examples: Proof of a Pending Adoption Include: Statement From An Attorney,
        Adoption Agency or Adoption-Related Social Service Provider.
If the Second Parent is Not Named in that Document;
  1)    They must also File Documentation Verifying the Relationship to the Parent
         Named in the Adoption.
  2)    If these Documents are not Available, the Second Parent May Submit other 
         Documentary Evidence of Parental Relationship to Child, for Evaluation by Carrier.

 

Family Member Care Forms to be Completed With Carrier Certification Required In Addition to Claim Forms

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Form PFL 1: Request PFL Benefits
• Part A: Employee To Complete
• Part B: Employer To Complete

Form PFL 3: Personal Health Info
• This Form allows the Health Care Provider to Complete PFL Form 4 and release it to the Employee Seeking PFL Benefits, the Health Care provider will retain this form.
• Do Not Send To the Insurance Carrier.

Form PFL 4: Health Care Provider

Certification for Care of Family Members with Serious Health Condition.             

Health Care Provider Completes

 

FORM PFL 4: Must Be Fully Completed

A Claim for Paid Family Leave to Care for a Family Member with a Serious Health Condition Requires:

1) A Medical Certification, Completed by the Care Recipient’s Health Care Provider.

An Authorization for Personal Health Disclosure Form is Required by the HIPAA Privacy Rule;

1) And Must be Completed by the Care Recipient and Retained on File with the
Health Care Provider in Order to Submit the Required Medical Information

 

Military Qualifying Event Forms to be Completed and Filed With Carrier Certification Required In Addition to Claim Forms

Of Employee's Spouse, Domestic Partner, Child or Parent

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Form PFL 1: Request PFL Benefits
• Part A: Employee To Complete
• Part B: Employer To Complete



Form PFL 5: Military Qualifying Event

Employee To Complete

A Claim for Paid Family Leave to Assist Loved Ones when a Family Member is Deployed Abroad on Active Military Duty Generally requires;

1) Either a Form PFL-5 “Military Qualifying Event” Certification or a
US Department of Labor "Certificate of Qualifying Exigency for Military Family
Leave.

Those forms include:
1) Military Documentation of the Family Member’s Deployment or Impending
Deployment (Active Duty Orders or Other Notice from the Military), and

2) Documentation of the Reason for Leave.
Documentation of Military Leave Signed by the Approving Authority For Military
Members Rest and Recuperation.