Disability/fmla Form Request - Orthopaedic Associates Of Michigan


Disability/FMLA Form Request
Received by
Today’s Date
(OAM use only)
1111 Leffingwell, NE, Grand Rapid, MI 49525
PHONE: (616) 459-7101 / FAX: (616) 336-5042
There will be a 7-10 business day processing time frame, as well as a processing fee based on the type of form. We understand you may
have an urgent deadline for your paperwork and will do our best to accommodate you; however all paperwork will be processed in the
order that we receive it without exception. By law, we are required to have you provide us with a signed authorization to disclose your
Patient’s Name (First, Middle Initial,
Last) ______________________________________________________________ ________
Date of Birth ________________________________________________ Daytime Phone # _________________________________
Email Address _________________________________________________________________________________________ _______
Mailing Address (Street, City, State, Zip) _______________________________________________________________ ________
□ Disability Forms ($20.00)
□ FMLA Forms ($20.00)
Purpose of disclosure (Check All That Apply):
***Fax or Mail completed forms to (MUST BE COMPLETED by Patient)***
of Company/Person to receive completed forms: ________________________________________________ _____________
Fax Number
of Company / Person to receive completed forms: (
to send completed forms to ( if NOT being faxed ): ___________________________________________________________
**Attach this form to the document to be completed for disability determination**
I authorize Orthopaedic Associates of Michigan to provide charts, notes, x -rays, operative reports, lab and medication records and
all other medical information about me, including medical history, diagnosis, testing, test results, prognosis and treatment of any
physical or mental condition. I understand this may include: any disorder of the immune system, including HIV, AIDS or other
related syndromes or complexes; any communicable disease or disorder; any psychiatric or psychological condition, including test
results; any condition, treatment, or therapy related to substance abuse, including alcohol and drugs; and any non -medical
information requested about me, including things such as education, employment history, earnings or finances, return to work
accommodation discussions or evaluations and eligibility for other benefits or leave periods including but not limited to claims
status, benefit amount, payments, settlement terms, effective and termination dates, plan or program contributions. I also
acknowledge I am responsible to pay the form completion fee as set in state statutes prior to form completion.
This authorization will expire one year from the date your signature below, unless you specify an earlier termination date. You must renew or submit a new
authorization after the expiration date to continue the authorization. Please list the date of expiration if earlier than one year from the date of execution of
this document:
You have the right to revoke or terminate this authorization at any time by submitting a written request to our Privacy Manager. Termination of this
authorization will be effective upon written notice, except where a disclosure has already been made based on prior authorization.
The practice places no condition to sign this authorization on the delivery of healthcare or treatment.
We have no control over the person(s) you have listed to receive your protected health information. Therefore, your protected health information
disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule and will no longer be the responsibility of the practice.
Patient or Representative Signature
Printed Name
Relationship (“Self” or Authorized Representatives Only*)
*Lega l paperwork for authorized representatives, i ncluding biological/adoptive parents, legal guardians and medical powers of a ttorney, must be
on fi l e.


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