FMLA/Disability/Medical LOA
Patient Information
Patient Name
Date of Birth
NOTE TO PATIENT: There is a
$40.00 fee
that will be collected upon receipt of this form.
For your convenience you can pay with a credit card through our secure PayPal account link at the end of this form.
Due to the increased volume of forms, we are filling out, we are asking that you respect our policy of a 7-10 business daytime frame for processing. Our nurse will call you when the form has been completed. We request that the patient fill out their portion prior to turning it in to us. We also need the following information to help us adequately process your forms:
1. Nature of injury/illness for this form. Example: flu symptoms, broken wrist, back pain, etc.
2. Date injury/illness first occurred
3. Dates you have been off work or expect to be off work: (intermittent?)
4. Date you returned or expect to return to work
5. Do you have a follow-up appointment scheduled?
Yes
No
With whom, and when?
6. Do you wish to
Pick up this form
Have this form mailed to you
Have this form faxed
Fax Number
7. What telephone number can we reach you at if we encounter more questions in processing your forms?
(please do not leave a pager number)
Consent To Disclose Protected Health Information
I
give my permission to disclose my health information to the following people listed below. I have the right to change, update or revoke this information at any time.
This consent is effective until
Company Name
Information to be disclosed
Medical
Billing
Appointment
Dates ranging from
to
Company Name
Information to be disclosed
Medical
Billing
Appointment
Dates ranging from
to
I understand that the information disclosed as directed above may be re-disclosed to additional parties and is no longer protected for reasons beyond our control.
You have a right to receive a copy of this consent if requested.
Completion of this consent is not a condition for treatment.
Please submit the $40 fee below before signing and submitting this form
Use the left button to pay with your debit card, credit card or PayPal
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Use the right button to pay with your Venmo account
Signature (required) – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.
Patient Date of Birth
Date