Fillable Short Term Disability Information printable pdf download

Short Term Disability Information

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SHORE ORTHOPAEDIC UNIVERSITY ASSOCIATES

SHORT-TERM DISABILITY INFORMATION

(Please allow 7-10 business days for completion)

Patient’s Name: __________________________________

DOB:_________________

Phone Number or Email for notice of Completion: ___________________________________

Your Shore Orthopaedic Physician:______________________________________

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

Approximate date of return: ______________________________

If you already returned to work, on what date did you return? __________________

**PLEASE SELECT ONE OF THE FOLLOWING**

*Please select office for pick up

Pick Up: Completed Form(s)

Somers Point

CMCH

Galloway

Email: Completed Form(s)

*Please provide your email address

_________________________________________

*Please provide a stamped envelope filled out with

Mail: Completed Form(s)

the address where you would like the form(s) mailed.

*Please provide Fax Number

Fax: Completed Form(s)

(

)_______________________________

Please Note: Once completed you will be notified.

However, you are responsible to make sure your forms

have been received at the desired location.

$10.00 fee per drop-off:

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

necessary to charge a drop off fee. 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 Placards.

*For UNUM, Met-Life or Prudential short-term disability forms, there is 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

claim is active.

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: __________________

1/27/16

Short Term Disability Information

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