Disability, Fmla & Paid Family Leave Questionnaire Form
ADVERTISEMENT
1DISABILITY, FMLA & Paid Family Leave QUESTIONNAIRE
Allow 5 Days for processing
An AUTHORIZATION FOR USE AND DISCLOSURE OF MEMBER/PATIENT HEALTH
INFORMATION must be attached
In order to process your claim; please COMPLETE ALL the information below.
Step1:
Check all that apply:
State Disability
Private Disability
FMLA
Paid Family Leave (PFL)
Step 2:
• Member/Patient must provide a Visit Verification of Treatment (VOT) from the treating
physician for dates of disability. Claim may be delayed if VOT is not available.
• A new VOT is required for extensions and should have a new return to work date.
Do you have a VOT from the treating Physician?
Yes
No
Patient Name: ___________________________
Medical Record Number: ________________
Phone Number: __________________________
SSN# _______________________________
Name of Treating Physician: _________________________________________________________
What is the specific condition? _______________________________________________________
If Pregnancy:
Due date_________________ Delivery date______________ Type:
Normal
C-Section
Step 3: State or Private Disability
First Date unable to Work: ______________Estimated or Actual Return to work date: ____________
Step 4: Family Medical Leave Act (FMLA)
Do you agree for Kaiser to provide medical facts or specific condition information at the
request of your employer?
Yes
No Initials____________
Is the FMLA to care for a Family member other than yourself?
Yes
No
If Yes, provide your name and relationship to the patient ___________________________________
Dates of FMLA: Starting:_
/
/
To:
/
/___
___
Is FMLA for a block of time?
Yes
No
If FMLA is for an ongoing CHRONIC CONDITION requiring INTERMITTENT TIME OFF:
How many episodes per month?_______ How many hours or days off per month?_______________
Step 5: Paid Family Leave (PFL): For Care of a Family Member
How many hours per day is required to care for the Family Member?_________________________
Dates of Care: Start:
/
/__ _
End Date of Care:
/
/
_______________
Internal Use Only
Disabiilty FMAL & Paid Leave Questonnaire Form -last updated 5/18/09
ejr
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business