Disability/fmla Request Form - Shoreline Orthopaedics printable pdf download

DISABILITY/FMLA REQUEST FORM

Patient: Please make sure that you have filled out all “Patient Information” sections on the

Disability/FMLA Forms that you are requesting we complete for you. The form(s) must also be signed

authorizing us to release medical information on your behalf.

Please provide the following information to help us complete your form promptly and accurately.

Patient Name: _____________________________________ Date of Birth:________________

Shoreline Physician:_________________________________ Today’s Date: _______________

Person Requiring Form, If Other Than Patient:________________________________________

Employer:______________________________ Job Title/Description:_____________________

Dates Off Work: From_____________________________ Thru__________________________

Who took you off from work?:_____________________________________________________

Reason off work:_______________________________________________________________

Remarks or concerns:___________________________________________________________

When forms are completed: (please check one)

_____ Call Patient

Phone # _______________________________

_____ Mail Form

Address _____________________________________________________

_____ Fax Form

Fax #_______________________________Attn:_____________________

Potential for Re-disclosure:

Information that is disclosed under this authorization may be disclosed again by the person or organization to which it is

sent. The privacy of this information may not be protected under the federal privacy regulations.

By signing this form, I am authorizing the release of my Protected Health Information as specified above or on

the form(s) that we have been asked to complete on your behalf.

Patient Signature: ______________________________________________________________

Charge of $15 for one form / $25 for 2+ forms / Same charge applies for any subsequent forms.

Payment must be made in advance. Forms will be completed within 5 business days from date received.

Office Use Only:

# of Forms Received _____________ Amt Paid ______________ Cash/Ck/CC Initials______________

Forms Completed: _______________ Mailed:__________________ Faxed:_______________________

Patient Pick Up: _________________ Initials:__________________

Disability/fmla Request Form - Shoreline Orthopaedics