Forms Completion Request For Disability/fmla - Dryer Medical Clinic printable pdf download

Forms Completion Request For Disability/fmla - Dryer Medical Clinic

Disability Depart ment/Medical Records

Ph: 630-859-7266 Fax: 630-264-8557

Office Use Only

Forms Completion Request For Disability/FMLA

Amount Paid: _________ Initials/LOC: _____________

Circle One: CC

CASH

CHECK

Please allow 10-15 business days for completion.

Please check all that apply: ___ FMLA($25) ___ Short Term Disability/Physician Statement($25)

___ Return to Work Form/Fitness for Duty(no charge)

Fee will be waived if patient chooses to receive forms through MyChart, patie nt is responsible for

submitting forms to insurance company and/or employe r.

PAYMENT IS DUE AT THE TIME OF SUBMISSION OF FORM(S).

Today’s Date:

MRN

(office use)

Patient’s Name:

DOB:

Are you requesting information related to care for a family member? If YES, please include the

following:

Your

Relationship

Your

Name:________________________ to Patient:________________ PH#:_____________________

Please choose ONE form of delivery:

MyChart (Fee waived if released by MyChart)

Mail to Patient or Organization

Fax #: ______________________ Recipient: _________________________________________

Pick Up (Location): ________________________ Phone #: ______________________________

Treating

Diagnosis/Condition/

Physician:

Injury:

Continuous (Single block of time

Modified Duty(lift, stand, sit, etc)

away from work)

Day off Work: ___________

Start date:___________

Return to Regular

Return to regular

Work Date: ____________

work date:___________

Inte rmittent (Periods of time away

Reduced Daily Hours

from work)

# of hours per day: _______

Start date:________

# of hours per week: ______

# of episodes per month: _______

Start date: ___________

# of days per episode: _________

Return to regular work date: __________

Hospital: ___Presence Mercy ____Rush Copley ____Cadence/Delnor

___ Dreyer Ambulatory Surgery Center ___Other _____________________________

Admission Date:__________________

Discharge Date: ____________________

Patient is to sign an Authorization to Release Medical Information on the

back of this form.

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Forms Completion Request For Disability/fmla - Dryer Medical Clinic

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