FMLA and Medical Disability Leave Forms

Please allow up to 10 business days to complete forms. Submit all forms to our FMLA and Disability Coordinator prior to your due date to avoid any delays in processing your paperwork.  Emergency issues will be handled in a priority manner.  All effort will be made to complete as quickly as possible.

You must complete all patient requested information and remember to sign and date.  Please do not complete any portion of the physician section.

Turn your paperwork in to the check out desk.  Do not give paperwork to your doctor, as this can cause a delay in completion.  Upon turning in your papers, please provide the office with your preferred method of distribution once they are completed, i.e., pick up in office, mail or fax to you or the company requesting the information.

Cost for completion of forms are as follows and payment is due when forms are left for completion:

  • Disability Form  (1 page)  $20
  • Family Medical Leave Act (FMLA) $20

By law, we are required to have a signed authorization from all patients prior to disclosure of their medical information to any outside source.  Most disability or FMLA forms include an authorization to disclose information page or paragraph to be signed by the patient.  If your paperwork contains this, please be sure to carefully read and complete that section by signing and dating where indicated.

If your forms do not include an authorization page or section, you will be required to sign our office authorization form prior to completion or release of these forms to anyone, including you.  Please note, this includes FMLA for your Spouse or relatives as well.  We must have an authorization from the patient before any medical information will be given.  The office authorization page can be found here.

Just a reminder, if your employer offers FMLA benefits, you are entitled to 12 weeks time off for the birth of a child.  However, our office only allows six weeks medical disability for vaginal deliveries and eight weeks for C-Section deliveries.  Any additional time off is between you and your employer.