Patient Disability / Insurance Claim Form
* = required fields
If your form(s) is/are for Pregnancy, please be aware that standard time off is 6 weeks following a vaginal delivery, and 8 weeks following a C-Section. If you are planning on taking more time off – before or after your Delivery – please indicate this on Question 7 and include the reason(s).
2. Name of Patient
3. Patient’s Date of Birth
4. Patient’s daytime phone number (where you can be reached in case of questions)
5. Reason for claim
6. Who is this form for?
7. What is the first planned day of leave?
8. What is the return date?
9. How long will the total leave be (weeks)?
If this is not the standard time off (as outlined above), please give your reason(s)
Has this been discussed with your doctor?
10. Will you return from leave on “regular” duties?
What type of restrictions apply?
11. When this form is completed, which would you like us to do?
Give to Front Desk Staff for you to pick up in 2 weeks
Provide a phone number
Mail it to:
Fax it to:
Provide a fax number
Additional Notes (if needed
Attach the appropriate files (if applicable)