Who is requesting leave?

We'll help you figure out exactly which medical leave programs you're eligible for.

Someone else

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.

Please enter your first name.

Please enter your last name.

What is the patients name?

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

Please enter your first name.

Please enter your last name.

What is the patients date of birth?

Please enter your date of birth:

Please select a date.

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:

The legal parent or guardian of the patient (if the patient is a minor), OR
The legally authorized representative (such as someone with power of attorney or other legal authority) for the patient (if the patient is an adult)
and have the authority to make this request.

I agree

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

I understand

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.

Yes

Is this your first time requesting leave?

Yes

Where are you in the process?

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

What are you looking for help with?

Select all that apply. It's okay if you are not sure. We'll help figure out what you qualify for!

Which benefits are you applying for?

Select all that apply. It's okay if you are not sure. We'll help figure out what you qualify for!

Great! We can help determine what you qualify for.

Most people qualify for more than one program. We'll check each one.

What benefits we'll qualify you for

Job-protected leave (FMLA)

Up to 12 weeks. Your job and health insurance protected.

Income replacement (state paid leave + short-term disability)

Replace 50–90% of your wages.

Workplace accommodations (ADA)

Modified hours, remote work, equipment.

To qualify, you must:

STEP 1: Work for a U.S. employer.

STEP 2: Have a qualifying work history.

STEP 3: Have a qualifying medical condition.

250,000+ employees evaluated

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

Have you been with your employer for one year?

This affects which programs you qualify for.

Yes

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

Roughly 24 hours a week. This affects which programs you qualify for.

Yes

Does your employer have 50 or more employees?

This affects which programs you qualify for.

Yes

You meet employment requirements for FMLA!

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

How FMLA Approval Works

STEP 1: Employment eligibility check

STEP 2: Confirm if your health condition qualifies for FMLA.

STEP 3: Meet with one of our healthcare providers to complete your FMLA forms.

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.

FMLA isn't a fit. But don't worry, you still have options.

FMLA needs 12 months on the job, 1,250 hours, and 50 employees at your worksite. You didn't meet all three. Other programs have different rules. State paid leave, short-term disability, and ADA accommodations all use different thresholds, and many of our patients qualify for at least one.

What's the reason you need time off?

This will help determine if you have a qualifying condition.

What's the main medical reason you need leave?

This will help us determine whether you meet the criteria of a "serious health condition".

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

If yes, we recommend you seek help elsewhere immediately. Trust Medical is not qualified to assist you in this situation

Yes

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?

A single overnight stay in a hospital qualifies as a serious health conditon.

Yes

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

Chronic conditions requiring periodic visits can qualify as a serious health condition.

Yes

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

If you have been incapacitated for three or more days and received treatment this also may qualify as a serious health condition for FMLA.

Yes

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

If so, this may qualify as a serious health condition for FMLA.

Yes

Great news! Your condition qualifies for other leave programs.

You have real options. State paid leave, short-term disability, and ADA accommodations can give you wage replacement and workplace flexibility while you're out, sometimes more than FMLA offers, since FMLA is unpaid.

You Meet the Criteria for Other Programs

Qualifying Condition:

Your condition meets the standard for state paid leave, short-term disability, and ADA programs.

Programs Available to You:

Paid family or medical leave: 50–90% of your wages, depending on your state.
Short-term disability: state programs (CA, NY, NJ, RI, HI) and employer plans replace income for weeks or months.
ADA workplace accommodations: modified hours, remote work, or equipment — at any employer with 15+ employees.

Next Steps:

We'll confirm how much time off you need.
We'll connect you with a healthcare provider for your video evaluation who will help you determine which programs fit your situation.
We'll complete your forms in less than 24 hours.

What's the reason you need time off?

This will help determine if you have a qualifying condition.

What's the main medical reason you need leave?

This will help us determine whether you meet the criteria of a "serious health condition".

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

If yes, we recommend you seek help elsewhere immediately. Trust Medical is not qualified to assist you in this situation

Yes

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?

A single overnight stay in a hospital qualifies as a serious health conditon.

Yes

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

Chronic conditions requiring periodic visits can qualify as a serious health condition.

Yes

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

If you have been incapacitated for three or more days and received treatment this also may qualify as a serious health condition for FMLA.

Yes

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

If so, this may qualify as a serious health condition for FMLA.

Yes

Great news! Your condition qualifies for FMLA and other leave programs.

Based on your answers, you qualify for FMLA and likely other leave programs.

You Meet All FMLA Requirements and May Qualify For Other Programs

Employer Eligibility:

You've worked for your employer for a year.
You've worked 1,250 hours in the last year.
Your employer has at least 50 employees.

Qualifying Condition:

Your condition qualifies under FMLA law.
You meet the standard for state paid leave, short-term disability, and ADA programs.

Other Programs You May Qualify For:

Paid family or medical leave: many states replace 50–90% of your wages.
Short-term disability: state programs (CA, NY, NJ, RI, HI) and employer plans replace income for weeks or months.
ADA workplace accommodations: your employer is 50+ (well above the 15+ threshold), so this likely applies.

Next Steps:

We'll confirm how much time off you need.
We'll connect you with a healthcare provider for your video evaluation who will help you determine which programs fit your situation.
We'll complete your forms in less than 24 hours.

How do you want to use your leave?

Don't worry if you're not sure - we will help you determine the best option during your consultation

Take a continuous block of time off

Take days off as needed

Work fewer hours or days per week

Not sure

How many consecutive weeks off do you need?

No worries if you're not sure. A healthcare provider experienced with leave certifications will guide you.

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

No worries if you're not sure. A healthcare provider experienced with leave certifications will guide you.

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

Employers can require you to re-certify your leave every 30 days. We make it easy, same physician, no new evaluation, just an updated form that can be handled without a live consultation.

Yes

Not sure

How soon do you need your leave certification?

We'll match you to a healthcare provider with the right availability that meets your timeline.

Today

Within 48 hours

Within the week

Other

No problem!

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

Your leave Certification Includes:

A video evaluation by one of our licensed healthcare providers.

Signed and completed leave forms within 24 hours.

Employer verification by our live support team.

Free modifications or adjustments as needed.

What is the name of your employer?

We'll use this information to help identify the correct paperwork, administrators, and leave process for your employer.

Please specify an answer

Have you already notified your employer that you need time away from work?

This includes notifying HR, your manager, a leave administrator, or an insurance company. We’ll use this information to understand where you are in the process.

Yes

Not sure

Does your employer offer Short-Term Disability (STD) benefits?

Yes

Not Sure

Has your employer or leave administrator provided you with forms to complete?

Yes

Some but not all

Not sure

No problem! We've got you covered.

We can help detemine what forms you need based on your consultation. Federal FMLA WH380, state forms (NY DBL, CA DE 2501), short-term disability forms, and employer/insurer forms, we complete them all. You don't need to figure out which one is right.

Is having a money back guarantee important to you?

Yes

We've got your back!

TrustMedical Design

Trust Medical is the only leave service that offers a 100% money back guarantee if you run into issues with your certification for any reason.

Did you know less than .01% of certifications written by our medical team are rejected?

Are you nervous about presenting your leave request forms?

Yes

We've helped 170,000+ people just like you.

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

Norman J. California

Jan 12, 2026

A service you can trust!

Chelsey K. Florida

1 day ago

Received forms fast, no issues!

Maria G Texas

Nov 7, 2025

So grateful this service exists.

Kelsey B. Arizona

June 28, 2025

They know what they are doing

What state are you in?

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

Are you currently receiving care for this condition from a healthcare provider?

This could include a doctor, therapist, psychiatrist, nurse practitioner, physician assistant, or other licensed healthcare provider.

Yes, I am actively receiving care

I have an upcoming appointment but have not yet been seen

No, I am not currently receiving care

Other

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.

Please specify an answer

What email should we send your completed forms?

We'll use this email to send your leave certifications and order status updates.

Please enter a valid email.

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Please specify an answer

What is your date of birth?

We need this information to include on your forms

Please enter your date of birth:

Please select a date.

What is the best number to reach you?

If you are unable to join your video call, your healthcare provider will contact you at this number to complete your evaluation.

Please enter a valid phone number

I agree to receive automated and personalized marketing text messages from Trust Medical at the number provided. Message and data rates may apply. Consent is not a condition of purchase.

I agree to receive sms from Trustmedical.

What is your name?

We need this information to include in your forms.

Please enter your first name.

Please enter your last name.

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.

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Please specify an answer

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

I agree

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

Your Trust Medical evaluation meets federal and employer standards, so your paperwork holds up and you take time off with peace of mind.

How did you hear about Trust Medical?

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

One missed filing can risk your job. Members never miss one.

Keep your job and paycheck protected every month, automatically.

FMLA, Paid Leave, and Short Term Disability aren't one-and-done. Your employer will demand recertifications, return-to-work, and ADA paperwork. Miss one and protections can be revoked.

Without Leave Protection

The bills stack up every time your employer asks for additional paperwork:

Recertification$175

Doctor's note$50+

Return-to-work or ADA form$75

HR and Benefits pushbackOn your own

$34.99/mo, billed only if approved. Cancel anytime.

What's included

Every future form, handled

Save $175 per recert, $75 per form

Recertifications, return-to-work, ADA accommodations. We file them all.

1 doctor's note every month

$50/mo value

Same-day, no video visit. Covers gaps during or after your leave.

Your own Leave Advisor

Get 100% of the benefits you're owed

One person who knows your case and handles HR and Benefits Company pushback.

100% refund guarantee

Any future filing we submit not approved? Full refund, no questions.

Yes, keep me protected

Thank you, @firstname1!

You are almost there.

What happens next:

Select a video appointment time with one of our licensed healthcare providers.

Complete checkout on the following page to confirm your appointment.

Complete your 10 minute video consultation, at your selected appointment time.

Receive your leave certifications and employer forms within 24 hours of your consultation.

Thank you, @firstname1!

You are almost there.

What happens next:

Select a video appointment time with one of our licensed healthcare providers.

Complete checkout on the following page to confirm your appointment.

Complete your 10 minute video consultation, at your selected appointment time.

Receive your leave certifications and employer forms within 24 hours of your consultation.

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