FMLA/Disability Form Completion Patient Authorization

Patient Name

Date of Birth (mm/dd/yyyy)

Address

City

State

Zip

Phone (XXX-XXX-XXXX)

Email Address (name@website.com)

Completed forms to be delivered to: Completed forms to be delivered to: Patient (to address above)

Third Party

Claim #

Fax # (XXX-XXX-XXXX)

Address

City

State

Zip

Anticipated date to leave work (mm/dd/yyyy)

Anticipated date to return to work (mm/dd/yyyy)

Anticipated Date of Healthcare Event (e.g., surgery, delivery, etc.) (mm/dd/yyyy)

Name of clinic

Please indicate your acceptance by checking the following boxes Please indicate your acceptance by checking the following boxes I understand that my treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization.

I understand that I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving the revocation.

I understand that if the requestor or receiver is not a health plan or health care provider; the released information may no longer be protected by federal privacy regulations and may be disclosed.

I understand that I may see and obtain a copy of the information described on this form, for a reasonable copy fee, if I ask for it.

I understand that I can request a copy of this form after I sign and date it.

Electronic Signature of Patient or Legally Authorized Representative

Date Signed (mm/dd/yyyy)

5 + 9 =

All forms are completed in the order that they are received.
A processing fee will be due prior to release of completed forms. An invoice will be delivered directly to the patient email address specified above with further instructions. Should you have questions, please call 972-895-2138.