Fmla And Disability Form Request - The Women'S Clinic Of Vancouver printable pdf download

FMLA AND DISABILITY FORM REQUEST

To our patients:

You, your employer, or your insurance company has requested that our clinic give out information for the

We ask that you understand that it may take at least 7-10

processing of FMLA and or disability benefits.

business working days to complete this request

. We only list periods of time off work estimated for medical

reasons. Employee benefits questions need to be directed to your employer or their benefits representative.

Prepayment is required for processing disability forms at $15.00 per form

. Checks are to be

made payable to: The Women’s Clinic of Vancouver, P.S.

To be sure we have the information needed for completing our medical portion of the form(s) regarding

your disability, please complete the following questionnaire, sign and date it.

Patient’s Name: ___________________________________last 4 of SSN:______DOB: _______________

Employee’s name: (if different) _______________________________Relation to Patient_____________________

3. Please check one of the 3 areas below and complete the section (how you use your employment

benefits for vacation or sick time will not be specified by a physician):

____MATERNITY LEAVE : (6 weeks is the normal length of time for vaginal delivery)

Estimated date of delivery __________________

Are there complications you feel are requiring you to stop working before your delivery date? _________

If you answered “yes”, please explain: _____________________________________________________

____INTERMITTENT LEAVE: _____Hrs per week OR _____________ days per week

Starting date of intermittent leave: __________________

Reason for intermittent leave: ______________________________________________

_____ SURGERY ______________________________________

Last day worked: _____________________Estimated Date you plan on returning to work: _____

INFORMATION RELEASED TO:

_____________________________________________________________________

Name of employer, short term disability company and or other entity which you authorize to receive your medical information.

____FAX form to fax #:_________________________________ Attn. to_______________________________

____CALL when completed for patient to pick up: #____________________________

____MAIL form(s) to: _____________________________________________________________________

“I authorize The Women’s Clinic of Vancouver, P.S., its representatives and agents to release all information

requested in my disability form to the company named above. I understand there will be a charge for completion

form and agree to pay the $15.00 fee prior to the release of the completed form from the clinic.”

____________________________________________________

_______________________

Signature

Date

Fmla And Disability Form Request - The Women'S Clinic Of Vancouver