Short-Term Disability Information - Shore Orthopaedic University printable pdf download

Short-Term Disability Information

(Please allow 7-10 business days for your form(s) to be completed)

Patient’s Name: __________________________ Date of Birth: _________________

Phone numbers and Contact info to reach patient during normal business hours:

Work: _________________

Home: ________________

Cell: _______________

Name of your Shore Orthopaedic Physician: _________________________________

If your form is for disability or leave of absence:

When was (or when will be) your first day out of work? _________________

How long does your doctor anticipate you will be out of work? ___________

If you have already returned to work, what date did you return? __________

Completed forms are to be picked up from one of our offices; please check which

office you prefer. You will receive a phone call once your form is ready for pick-up.

____Somers Point

____Galloway ____Cape May Court House

Due to the volume of requests to complete disability paperwork, it is necessary to

charge a $10.00 fee per drop-off for this service. Our office recommends dropping

off all forms you may need at one time. This fee WILL NOT be imposed for NJ

State Disability Forms or Handicapped Placard requests but does apply to all other

disability paperwork.

For UNUM, Met-Life, or Prudential short-term disability paperwork, your fee will

be a one-time fee of $20.00. This fee will encompass all of the requested updates and

records requests during the time your short-term disability claim is active.

Please allow 7 - 10 business days for completion of all paperwork. We will not

mail any paperwork unless we are provided with a stamped, addressed envelope.

Faxing of forms is permitted if the request is in writing.

Authorization to release information: I hereby authorize Shore Orthopaedic University Associates to

release information to my insurance carrier(s), employer, or others I request concerning my illness

and treatments.

Signature of Patient: __________________________________ Date: __________________________

2/5/15

Short-Term Disability Information - Shore Orthopaedic University