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Disability & Family Medical Leave Information Form - R.b. Kolachalam M.d. General Surgery

R . B . K O L A C H A L A M

M . D .

G E N E R A L S U R G E RY

D I S A B I L I T Y & F A M I LY M E D I C A L L E AV E

I N F O R M A T I O N F O R M

Please Read Carefully

1. The patient must complete their portion of the form completely. If you have

questions while ﬁlling out your portion of the form, please contact your

employer or human resources department. Unfortunately, we do not have the

staff or time to assist you with this process.

2. We cannot accept faxed forms from your insurance company. The FMLA form

should be faxed to YOU. Once you have completed your portion of the form,

please bring the form to our office to complete.

3. All forms must have the ﬁrst day the patient missed work as well as the

date the patient is expected to return to work.

4. The patient must sign the form allowing R.B. KOLACHALAM GENERAL SURGERY to

release medical information.

5. PLEASE ALLOW AT LEAST 5 WORKING DAYS TO COMPLETE THE FORM.

In order to properly complete your disability or FMLA form, our staff must

completely review your medical records, therefore the form cannot be

completed the same day it is brought to the office.

Name of the patient (please print): __________________________________________

Date last worked: ______________

Date expected to return to work: ______________

Date(s) of hospitalization: ________________ Date form received: ________________

Phone number of patient: _______________ Fax number (to fax form): _____________

Signature of patient: ___________________________

THERE WILL E A $25.00 CHARGE FOR EACH INSURANCE FORM

COMPLETED

T 248-662-4272

F 248-662-3020

26850 Providence Parkway Novi, MI 48374

Disability & Family Medical Leave Information Form - R.b. Kolachalam M.d. General Surgery