FMLA / DISABILITY FORM REQUEST
Patient Name:
*
Patient Date of Birth:
*
/
Month
/
Day
Year
Date
Usual Provider:
*
If form is not for the patient, please indicate name of person:
Relationship to Patient:
There
is a fee for
each
form that needs to be completed
.
The form is typica
lly completed within 7
-
10 business days
from date of p
ayment
.
Please ensure that you have only completed the “patient” portion of your form. W
e are unable to submit forms
in which the “physician/provider” portions
have been completed (even in part) by so
meone other than an
Alliance Ob
-
Gyn staff member.
Fo
rms are completed for medically indicated time off work ONLY. Any additional time that you are eligible for
under FMLA must be coordinated by you and your employer.
Patient Signature:
*
Today's Date:
*
/
Month
/
Day
Year
Date
1) What is the reason for your disability?
*
Pregnancy
Surgery
What type of leave?
*
Intermittent Leave
Continuous Leave
Unsure
Date of your surgery?
-
Month
-
Day
Year
Date
What was your delivery date or expected due date:
/
Month
/
Day
Year
Date
Have you stopped working? If so, please indicate the date.
/
Month
/
Day
Year
Date
Please provide any additional information that you feel will be helpful for us when completing the form(s).
Upload the form(s) you need us to complete. The employee portion on your form(s) must be completed prior to submitting, there will be additional delays if not completed:
*
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Cancel
of
Once form is completed, please indicate below how you would like us to proceed with completed form(s):
*
Fax (enter fax number below)
Mail (enter address below)
Pick Up
Original Forms Required
Fax to:
Mail to:
Submit
Should be Empty: