[Your Health Care Provider’s Letterhead]
To whom it may concern:
I am the [treating physician, nurse practitioner, nurse midwife, licensed midwife, clinical psychologist, clinical social worker, licensed marriage or family therapist, licensed acupuncturist, physician assistant, chiropractor, social worker, or health care professional] for [Your Name].
[Name] needs to take pregnancy disability leave because she is disabled by pregnancy, childbirth or a related medical condition. [Note: You do NOT need to reveal a diagnosis or details of the disability, but you do need to state that the patient has a pregnancy- or childbirth-related disability.]
[Name] became disabled by pregnancy, childbirth or a related medical condition on [Date]. At this time, I anticipate that she will need to remain on leave for [estimated duration of disability leave].