Certification of Health Care Provider

To be used for medically-related Leaves of Absence

If you take a leave of absence for your own or a family member’s serious medical condition, you must provide a complete Certification of Health Care Provider form. The form must be completed by your physician or other appropriate health care provider. It documents your eligibility for the protection offered by the federal Family & Medical Leave Act and the Oregon Family Leave Act. This form should be submitted to Benefits with your PCC Leave of Absence Request, or within 15 days of the date requested, in accordance with state and federal law.

Return all Certification of Health Care Provider forms or other medical statements or documents to:

PCC – Benefits
SY CC 102
P.O. Box 19000
Portland, OR 97280-0990

Or Fax: 971-722-5604

Release to Return to Work

If the Leave of Absence is for your own health condition, you must submit a Fitness for Duty form from your doctor before returning to work. The form must include any restrictions or limitations you may have in performing your job duties at PCC.

A release to return to work is not required 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 email benefits-group@pcc.edu.