Patient Disability / Insurance Claim Form
* = required fields
Note:
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).
1. Date
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
Pregnancy
Surgery
Other
6. Who is this form for?
Yourself
Husband
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?
Yes
No
10. Will you return from leave on “regular” duties?
Yes
No
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
Call you
Provide a phone number
Mail it to:
Name
Address
City
State
Zip
Fax it to:
Provide a fax number
Additional Notes (if needed
Attach the appropriate files (if applicable)