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Welcome to the New Jersey Division of Family Leave Insurance web application for family leave benefits. This application allows a health care provider to complete the medical certification necessary to process New Jersey Family Leave Insurance benefits for your patient’s caregiver.

To file the medical certification pertaining to your patient’s need for a caregiver, you will need their online form ID. This number can be found on the Medical Certification online filing instructions in Block 5, or your patient can provide you with the online form ID. The online form ID cannot be obtained in any other manner.

You will need approximately fifteen (15) minutes to complete this certification. If your computer is idle for longer than thirty (30) minutes, the application will automatically close.

Read all questions carefully. This information regarding your patient’s condition will be used to determine the caregiver’s right to benefits. Review the medical information summary before you submit the medical certification to ensure that all information you have provided is correct. Incorrect information could result in a delay in processing the caregiver’s claim. Record the Confirmation Number or print the confirmation page after you submit the medical certification. This number is proof that you successfully submitted the medical certification.

Questions noted by an asterisk (*) are required and must be answered. You will not be allowed to proceed until that question has a response.

If you require any assistance in filing the medical certification, please call our Customer Service Section at (609) 292-7060.

Precautions are taken to keep the information you provided in this application private and secure. The online application uses a secure connection and the data submitted is encrypted. Using a shared computer to complete this application may enable others to view the medical certification.