NJ TEMPORARY DISABILITY
AND FAMILY LEAVE INSURANCE
GUIDANCE FOR MEDICAL PROVIDERS
If any information is missing or illegible, we will send another form to the applicant asking for this information
from you. This could delay claim processing an additional 4-6 weeks or result in a denial of benets.
P
Be sure to include an actual date for the prognosis. “TBD, unknown” or leaving it blank could
result in a shorter duration of approved benets. If unsure, please estimate the date or provide
the date of the patient’s next scheduled visit.
NJ Temporary Disability Insurance provides cash benets to employees in NJ who are unable to work due to a
compensable physical or mental health condition or other disability unrelated to their work, including pregnancy/
childbirth recovery and COVID-19.
NJ Family Leave Insurance provides cash benets to employees in NJ who are unable to work because they need
to bond with a new child, care for a family member with a physical or mental health condition (including COVID-19;
see the generous denition of “family” under the law at myleavebenets.nj.gov), or handle certain matters related
to domestic or sexual violence.
See myleavebenets.nj.gov for helpful information to share with your patients and staff.
What is the medical provider’s role in Temporary Disability and Family Leave
Insurance applications?
For Temporary Disability Insurance, your patient is applying for benets; for Family Leave Insurance, the caregiver
of your patient is applying for benets. Online applicants are responsible for providing you with their Form ID after
completing their portion. Once you receive their Form ID, it is your responsibility to complete the online medical
section certifying their disability or need for care. Paper applicants must provide you with their application to
complete your portion. You or the applicant can fax or mail the completed application to us.
P
Forms completed by a PA-C must be certied/signed by the supervising physician.
We encourage online applications, however, this may not be possible for some applicants. Kindly consider printing
applications for those who need them at: myleavebenets.nj.gov/paperapp.
When should I submit the medical section?
Once the applicant provides you with the online Form ID, submit the medical section within 14 days of the request,
or claim processing could be signicantly delayed for your patient or their caregiver.
P
Applicants ling online may start their applications 60 days in advance of the anticipated
period of leave.
What information do I, as the medical provider, need to provide?
Complete the medical section form in its entirety, including:
•
Dates the patient is under medical supervision
•
First day of disability or date the patient requires care
•
Diagnosis
•
Prognosis date
•
Pregnancies: due date, delivery date & complications
during pregnancy (if applicable)
•
Signature and date
•
Your medical license number
Can I charge my patients or their caregivers to complete their medical forms?
No. N.J.S.A. 12:18-1.6 prohibits medical providers from charging a fee to complete Temporary Disability or Family
Leave Insurance forms.
Is the online application secure?
Yes. The information you submit is encrypted, and the system meets all state-mandated security standards.
P
Online medical certications are strongly recommended but you may also submit a paper
medical section to the Division by mail or fax.
Benets for new & expectant parents
Temporary Disability Insurance can provide cash benets for expectant parents when they need to stop working
before giving birth and while recovering. Birthing parents can transition directly to Family Leave Insurance to bond
with their newborn baby. Family Leave Insurance is also available for non-birth parents to bond with their newborn,
newly adopted, or newly placed foster child within a year of birth or placement.
Benets related to COVID-19
Your patient could be eligible for Temporary Disability Insurance benets if you certify that they are unable to work
because they were diagnosed with COVID-19 or are at high risk for COVID-19 due to an underlying health condition.
In addition, a patient’s caregiver could be eligible for Family Leave Insurance benets if you certify their need for
care due to having COVID-19.
Do these programs provide job protection?
These are wage replacement programs and they do not provide job protection. However, patients and caregivers
may be covered separately under the Federal Family and Medical Leave Act (FMLA), the New Jersey Family Leave
Act (NJFLA), the New Jersey Security and Financial Empowerment (SAFE) Act and/or COVID-19 related job protec-
tion during the Public Health Emergency. Learn more at myleavebenets.nj.gov/jobprotection.
For more information on Family Leave and Temporary Disability Insurance see myleavebenets.nj.gov.
T: 609-292-7060
MONDAY-FRIDAY
8:00 am – 4:30 pm
F: 609-984-4138
Temporary Disability and
Family Leave Insurance
PO Box 387 | Trenton | NJ | 08625
For further assistance
PR-151 (3-21)
