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
26850 Providence Parkway Novi, MI 48374