What is your name?

We need the name of the parent/guardian authorized to request the leave certificate on behalf of the patient in order to approve requests on behalf of someone else.

What is the patients name?

Please provide the name of the person you are requesting the certificate on behalf of.

What is the patients date of birth?

I, @GuardianFirstName @GuardianLastName, authorize the release of medical information and the issuance of an FMLA Certification note for, @MinorFirst-Name @MinorsLastName. I confirm that I am either:

Please provide the patient's symptoms and medical details when requesting a certificate.

Are you over the age of 18?

Note: Patient's under the age of 18 will need a guardian to be the point of contact for our healthcare providers. 

Is this your first time requesting leave?

We’ll help you get clarity on what to do next.

Great! We can help determine if you qualify.

The next few questions will determine if you meet the above requirements.

Have you been with your employer for one year?

This determines your eligibility for FMLA.

Have you worked at least 1250 hours in the last year?

This is roughly 24 hours per week on average and determines your eligibility for FMLA.

Does your employer have 50 or more employees?

This determines your eligibility for FMLA.

You work for a covered employer, and meet job history requirements. You are eligible for FMLA.

Next, we will determine if you have a qualifying condition.

Unfortunately, we cannot provide FMLA documentation for patients under 18 years old. 

Please have your parent or legal guardian complete this request form.

Unfortunately, you do not qualify for FMLA. 

You must have worked with your employer for at least one year, a minimum of 1250 hours, and your employer must have 50+ employees.

This will help determine if you have a qualifying condition.

What’s the main medical reason you need FMLA leave?

Over the past two (2) weeks, have you had thoughts of suicide?

Trust Medical Is Not Qualified To Help You. 

Please click here for access to mental health resources that might better support you.

Have you been hospitalized overnight or received inpatient care recently?

Do you see a healthcare provider at least twice a year for this condition?

Has your condition made you miss 3 or more days of work?

Has your healthcare provider said this condition is chronic, ongoing, or long term?

Great news! Your condition qualifies for FMLA.

Based on your answers, you qualify for FMLA.

How do you want to use your FMLA leave?

How many consecutive weeks off do you need?

How many days off do you need (per month)?

Will your employer require you to re-certify your FMLA?

How soon do you need your FMLA certification?

No problem! 

Our healthcare providers complete FMLA certifications in less than 24 hours.

Your FMLA Certification Includes:

Do you already have your FMLA forms or do you need help getting them?

No problem! The most common FMLA form is the WH380.

The WH380 is the standard federal FMLA request form, and is accepted nationwide. If your employer did not provide you forms, we'll use the WH380.

Is having a money back guarantee important to you?

We've got your back!

Are you nervous about presenting your leave request forms?

Our process is compliant with all federal FMLA laws and guidelines. Our team has helped thousands of patients just like you.

What state are you in?

We'll match you to a healthcare provider licensed in your state. 

Do you need help with any forms besides FMLA?

Our medical providers can help with paid leave, short-term disability, and work place accommadations.

What other forms do you need help with?

Select all that apply.

NOTE: State paid programs are only available in specific states.

Got it! Do you have an official diagnosis from a healthcare provider?

This documentation is required to complete your leave forms.

Do you see a health care provider for your condition?

This documentation is required to complete your leave forms.

Do you have an ongoing plan of care for your condition?

This documentation is required to complete your leave forms.

Do you already have your paid leave forms or do they need to be completed online?

Note: Paid Leave and FMLA are two different types of forms.

Do you need help with any of these right now?

You'll get your FMLA and paid leave forms first and a provider will discuss your options for anything else you select.

What can we help you with?

Your provider will talk through this with you during your consultation.

What email should we send your completed forms?

We'll use this email to send your FMLA certification and order status updates.

What is your date of birth?

We need this information to include on your forms

What is the best number to reach you?

What is your name?

We need this information to include in your forms.

Please check your information.

Before you continue, please make sure your information is correct.

Full Name: @firstname1 @lastname

Date of Birth: @DOB

State: @state

Email: @email

IMPORTANT: We use this information for your leave certification.

By continuing, I agree to TrustMedical's terms & conditions, privacy policy, HIPAA consent and telehealth consent.

FMLA & paid leave requires a video consultation, we've got you covered!

How did you hear about Trust Medical?

Thank you, @firstname1! 

You are almost there.

What happens next:

Your Short Term Disability and FMLA needs to be recertified periodically.