Short Term Disability Consent Form - Concord Ob Gyn printable pdf download

Concord OB/GYN

Short-Term Disability Consent Form

Maternity and Surgical

59 ORNAC, Suite 1

Concord, MA 01742

(978) 369‐7627

Fax (978) 371‐2240

Dear Patient,

The Physician's Statement portion of your Short-term Disability Claim Form will be completed for you by our

staff. This is typically done towards the end of your pregnancy, when surgery is scheduled, or after delivery;

unless you are medically released from work earlier.

Please note: Most insurers allow 6 weeks following a vaginal delivery or eight weeks following a Cesarean

section for your period of medical disability only. Extension of your leave from work beyond this period, such

as FMLA, approved leave without pay, etc., is separate from your medical leave.

We can also complete the Physician's section of your FMLA form and Paternity Leave Claim Forms, as well as

Return to Work letters, and other appropriate documentation as needed.

To expedite the processing of your Disability Claim, please provide the following information:

Your name_________________________________________________ DOB____________________

Day phone: _____________________________ Eve phone: ________________________________

Your due date: ______________ or date of scheduled C-Section or Surgery: ____________________________

Duration of Leave: _____________________________ weeks (# of weeks)

Other/Problem: _____________________________________________________________________________

Your signature below authorizes this office to release medical information to your Human Resources Department

and/or your Disability Insurance Carrier:

Signature

Date

Please fill out and attach this Consent Form to your Disability Claim Form, making sure that the address or fax

number to which you want it sent is provided.

Alternatively, present this completed Consent Form to a member of our staff earlier in your pregnancy, to be

retained in your chart until your Disability Claim Form arrives at or near your delivery/surgery date.

Thank you for helping us to expedite your claim!

Concord OB/GYN

Short Term Disability Consent Form - Concord Ob Gyn