Certificate of Health Care Provider Information

To be used for medically-related Leaves of Absences

The Certificate of Health Care Provider form is to be completed by your physician or other appropriate health care provider. This is the documentation for the employee's eligibility for the protection offered by the federal and state family medical leave act (FMLA). This Certificate should be submitted with the PCC Leave of Absence Request, or within 15 days of the date the request for leave of absence is made, in accordance with Oregon and Federal regulations for Family & Medical Leaves.

Depending on whose medical condition the leave is for, have the health care provider fill out the appropriate certificate.

Return all Health Care Provider Certificates or other medical statements or documentation to:

PCC - HR, Downtown Center 321
P.O. Box 19000
Portland, OR 97280-0990

Or Fax: 971-722-5877

Release to Return to Work

If the Leave of Absence is for the employee’s own health condition, PCC requires the employee to submit a statement from their Health Care Provider releasing him/her to return to work. The statement needs to include any restrictions or limitations the employee may have in performing their job duties at PCC.

A release to return to work is not required for the employee if the Leave of Absence is for a family member’s health condition.


If you or your Health Care Provider have questions regarding your Leave of Absence, please call 971-722-5859.