Can a physiotherapist issue an L4 note?

A patient finishes a session and asks: "Could you give me an L4 for this week?" Or: "Since you've been treating me for a month, could you write me a prescription for an ointment?" For the patient this feels natural. For you it is a question about the limits of your profession, and the answer must follow the law and be recorded in your documentation.

In short: a physiotherapist cannot issue an L4, that is, a medical certificate of temporary incapacity for work. The provision names a doctor, a dentist, a feldsher and a senior feldsher. Physiotherapists are not on that list. Below we go through what the law says about L4, prescriptions, referrals and exemptions from PE classes, and what you can issue yourself.

Key takeaways

• An L4 (a medical certificate of incapacity for work) is issued by a doctor, a dentist, a feldsher or a senior feldsher. A physiotherapist is not on that list (Article 54(1) of the Sickness and Maternity Cash Benefits Act).
• A doctor may authorise a person practising a medical profession to issue certificates on the doctor's behalf, but that is the doctor's decision and the doctor's responsibility, not a physiotherapist's entitlement.
• A physiotherapist may order medical devices and issue opinions and rulings on a patient's functional state, as long as their professional title and length of practice allow it.
• An exemption from PE classes is based on a doctor's opinion (the Ministry of Education regulation on assessment), so it is not a physiotherapist's document.
• It is worth noting the patient's request for an L4 and your response in the patient record.

Who issues an L4 under the Act

"L4" is the everyday name for the medical certificate on the basis of which ZUS (the Social Insurance Institution) pays sickness benefit. The Act on Cash Benefits from Social Insurance in Case of Sickness and Maternity calls it a "medical certificate" and states expressly who may issue it.

Under Article 54(1) of the Act, ZUS authorises a doctor, a dentist, a feldsher or a senior feldsher to issue medical certificates. The authorisation follows a declaration that you undertake to follow the rules for determining temporary incapacity for work. The certificate is issued electronically in a system provided by ZUS (Article 55(1)) and contains, among other things, the issuer's licence number and the statistical disease number under the ICD classification (Article 55(3)).

Two things follow directly:

1. Determining incapacity for work due to illness is a task of the professions listed in the benefits Act. The Act on the Physiotherapist Profession does not give this task to physiotherapists.
2. Even when a patient has had your functional assessment and you can see they should not lift anything, you have no tool to issue a ZUS sick note yourself.

What about authorisation from a doctor

Article 54a of the benefits Act allows a doctor who has a profile in the ZUS system to authorise a person practising a medical profession, or performing auxiliary tasks in providing services, to issue certificates on the doctor's behalf. The conditions are narrow:

• the certificate is issued on the basis of data on incapacity for work contained in medical records prepared by the doctor,
• the authorisation lasts up to 12 months and the doctor may withdraw it at any time,
• the doctor is responsible for the consequences of a certificate wrongly issued by the authorised person (Article 54a(6)).

This is not a physiotherapist's competence but a doctor's delegation within the doctor's own records. If you run a physiotherapy practice without a certifying doctor, this provision does not apply to you. If you work with a doctor in one facility, you agree the terms of such a delegation in writing and the doctor is responsible for it.

Prescriptions and referrals: what the law says

Prescriptions for medicines

Article 4(2) of the Act on the Physiotherapist Profession lists what practising the profession involves. It includes functional diagnostics, physical therapy, kinesitherapy, massage, ordering and selecting medical devices, physiotherapy prevention, and issuing opinions and rulings. Issuing prescriptions for medicines is not in that list. The Pharmaceutical Law, in the provision on forms of prescriptions (Article 95b(2)(5)), refers to a prescription issued by a doctor, a nurse and a midwife, and we did not find physiotherapists there.

We did not check the implementing regulations on prescriptions or the professional acts for other professions. If a patient asks for a medicine, you refer them to a doctor or a pharmacist.

Orders for medical devices

Here a physiotherapist has a real entitlement. Article 4(2)(5) of the Act on the Physiotherapist Profession lists ordering medical devices on the terms set out in the reimbursement act, and Article 40a of the Act on Healthcare Services Financed from Public Funds provides that a supply of medical devices is available on the basis of an order issued by a physiotherapist.

Mind your professional title. Article 4(5) says that a physiotherapist with a bachelor's degree or a physiotherapy technician title who has the required length of practice may not order medical devices or issue opinions and rulings under paragraph 2, points 5 and 9. So the scope depends on your education and experience (Article 4(4)).

Referrals

A private patient does not need a referral to see you. We described the rules on working with doctors and referrals for treatment in the article on working with doctors and referrals. Here we point to one thread from the Act on the Physiotherapist Profession: a physiotherapist without the required professional experience may provide services only on the basis of a referral from a doctor or from another physiotherapist who has the right to provide services independently (Article 4(4a)). So a referral from a physiotherapist does exist in the law, but it concerns cooperation within the profession. It does not replace an L4 or a referral to a specialist.

We did not check the rules on referrals to services financed by NFZ (the National Health Fund) in this article.

Exemption from PE classes and other certificates patients ask for

The parent of a young patient often asks about an exemption from physical education lessons. The Minister of National Education regulation on assessing, classifying and promoting pupils (§ 4(1) and (2)) says that the school principal exempts a pupil from specific exercises or from the whole class on the basis of an opinion issued by a doctor. The regulation does not name a physiotherapist as someone who issues an opinion for this purpose.

What can you do? You can issue a physiotherapy opinion on the child's functional state and the course of therapy, if the parent asks for it and you have the entitlement under Article 4(2)(9). That does not replace the medical opinion required by the school regulation. Tell the parent this plainly so they do not come back from school with a refusal.

What a physiotherapist can issue and how to document it

Beyond orders for medical devices, you have several documents that follow from your profession.

Document	Basis	Notes
Opinion or ruling on the patient's functional state and the course of physiotherapy	Article 4(2)(9) of the Act on the Physiotherapist Profession	Depends on title and length of practice (Article 4(4) and (5))
Ruling on medical rehabilitation under ZUS disability prevention	Article 4(2)(9a)	Concerns rulings for ZUS, not an L4
Order for a medical device	Article 4(2)(5); Article 40a of the Act on Healthcare Services	Depends on title and length of practice
Certificate, ruling or physiotherapy opinion issued at the request of the patient or authorised entities	§ 62(1)(2) of the regulation on medical records	External documentation

In the individual physiotherapy care record you note information about rulings, opinions or certificates issued and about medical devices ordered (§ 49(4)(1)(e) and (f)). We described the record fields in the article on the patient record, and the general rules for keeping entries in the guide to medical records in physiotherapy.

How to respond to a patient who asks for an L4

Best to keep it short and calm, without explaining the law during the visit. A sample script:

1. Acknowledge the patient's problem: "I understand this week is difficult for you."
2. Say who issues an L4: "A doctor issues the ZUS sick note, I don't have that authority."
3. Offer what you can do: a description of their functional state and recommendations that the patient can show the doctor.
4. If the symptoms worry you, point to a doctor as the next step and note it in the record.
5. Record it: date, the patient's request, your response, any referral to a doctor.

Such an entry takes a minute, and in a dispute with a patient it shows that you knew the limits of your profession and kept to them. Like the consent for a procedure we discuss in the article on patient consent to a physiotherapy procedure, it is a piece of documentation that protects both sides.

Frequently asked questions

Can a physiotherapist issue a medical sick note?

No. A medical certificate of temporary incapacity for work, on the basis of which ZUS pays benefit, is issued by a doctor, a dentist, a feldsher or a senior feldsher (Article 54(1) of the benefits Act). Physiotherapists are not in that provision.

Can a physiotherapist write a prescription?

The list of professional activities in Article 4(2) of the Act on the Physiotherapist Profession does not include issuing prescriptions for medicines. You can, however, order medical devices if your professional title and length of practice allow it.

Can a physiotherapist issue a referral?

A referral from a physiotherapist appears in the Act on the Physiotherapist Profession in Article 4(4a), as a basis for services provided by a physiotherapist without the required experience. It does not replace a medical referral required for services whose rules are set by other provisions. We did not check NFZ rules.

Can a physiotherapist issue an exemption from PE?

The regulation on assessing pupils ties an exemption from PE to a doctor's opinion (§ 4(1) and (2)). You can issue a physiotherapy opinion on the child's functional state, but the school may not treat it as a sufficient basis for an exemption.

Can a doctor authorise a physiotherapist to issue an L4?

Article 54a of the benefits Act allows a doctor to authorise a person practising a medical profession to issue certificates on the doctor's behalf, on the basis of the doctor's records, for up to 12 months. The doctor is responsible for the consequences of such certificates. This is an organisational arrangement within the doctor's facility, not an entitlement that comes from the physiotherapist profession.

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Legal status as of: 2 November 2026

Legal basis: Act of 25 June 1999 on Cash Benefits from Social Insurance in Case of Sickness and Maternity (consolidated text Journal of Laws 2026 item 854), Articles 53-55 and 54a; Act of 25 September 2015 on the Physiotherapist Profession (consolidated text Journal of Laws 2026 item 584), Articles 2, 4 and 6; Act of 27 August 2004 on Healthcare Services Financed from Public Funds (consolidated text Journal of Laws 2025 item 1461), Article 40a; Pharmaceutical Law (consolidated text Journal of Laws 2026 item 612), Article 95b; Minister of National Education regulation of 22 February 2019 on assessing, classifying and promoting pupils and students in public schools (consolidated text Journal of Laws 2023 item 2572), § 4; Minister of Health regulation of 6 April 2020 on medical records (consolidated text Journal of Laws 2026 item 1391), §§ 49 and 62. We did not check: implementing regulations on prescriptions, professional acts for doctors, nurses and feldshers, rules on referrals to services financed by NFZ, details of using the ZUS system, or changes to the Ministry of Education regulation made after the consolidated text was published.

Last reviewed: 2 November 2026

The TARCZA package contains instructions and a template for the patient record, a therapy plan, a treatment log, a treatment consent and rules on storing records, where you can note, among other things, opinions issued and responses to patients' requests. See the TARCZA package or compare packages.

Related articles:
- Working with doctors - referrals and documentation
- Patient record in physiotherapy - template and fields
- Medical records in physiotherapy
- Patient consent to a physiotherapy procedure