FMLA/DISABILITY DOCUMENTS

FMLA/Disability Documents
PATIENT NAME*

First NameLast Name
PATIENT DOB*

MonthDayYear
Date
Patient Signature*

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PLEASE NOTE IT WILL TAKE 7-14 BUSINESS DAYS TO COMPLETE PAPERWORK. IF YOU NEED PAPERWORK EXPEDITED, (LESS THAN 7 DAYS) THERE WILL BE A $50 CHARGE.
Patient Notes:
*REQUEST FOR FAXED FMLA/DISABILITY PAPERWORK, PLEASE READ BELOW AND COMPLETE THE NECESSARY INFORMATION.
At this moment, I authorize Celebration Obstetrics and Gynecology to release FMLA/DISABILITY paperwork to the following: *
NAME OF ORGANIZTION
In-person pick upEmailedFaxedOther
Employer FMLA Paperwork

(Upload your documents here. )
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Attention to:
Email
example@example.com
Fax Number
Please enter a valid fax number.Format: (000) 000-0000.
Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
YES- $25YES - $50NO - ON PICKUP
Signature *

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Should be Empty:

FMLA/Disability Documents