Short Term Disability Request Form printable pdf download

Short Term Disability Request Form

Personal Information

Employee Questionnaire

Name____________________

Date of Birth_________________

Address__________________

E-mail Address_______________

_________________________

Telephone___________________

Social Security____ ____ ___

Job Title_____________________

Short-term Disability Questionnaire

What dates are you unable to work due to disability? _____________

Short Term Disability Claim Form - Employee Questionnaire

2. Did you receive a diagnosis, medical care, services, treatment, advice or

recommendations for this disability? Yes___

No____

3. If yes, what date did you or will you receive the following:

A. Diagnosis ________________ B. Medical Care___________________

C. Services ________________

D. Treatment ____________________

4. Expected Return to Work Date?_____________ (

Attach FMLA and physicians

documentation to form).

AUTHORIZATION TO DISCLOSE INFORMATION

(This Authorization complies with the HIPAA Privacy Rule)

I CERTIFY that the above statements are true, complete and correct to the best of my knowledge

and belief.

I understand that Wilberforce University will provide short term disability pay in an

amount equivalent to seventy-five percent (75%) of the employee’s regular weekly straight time

pay beginning on the fifteenth (15

) day of disability and continuing through the ninetieth (90

)

day of disability.

I authorize any physician, health care professional, hospital, clinic, laboratory,

pharmacy or pharmacy benefit manager, other medical or medically related facility or provider,

clearinghouse, health plan, insurance or reinsuring company, agent, broker, service provider, credit

bureau or other consumer reporting agency, employer, the Veterans Administration, the Medical

Information Bureau, Inc., or any other personal or business associate to disclose any and all

information related to said disability.

Signature _______________________

Date _______________________

Short Term Disability Request Form