HYPOSPADIAS SPECIALTY CENTER - FMLA REQUEST FORM

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Patient Name* This field is required.
First Name
Last Name
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Date of Birth* This field is required.
Month
Day
Year
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Office Policies for FMLA and Short Term Disability Forms

It is the patients responsibility to bring in, fax, or email the correct forms to our office for completion by the medical staff.

The patient or patient family is required to provide a copy of his/her job description with the paperwork in order to accurately complete the forms.

The employee portion should be completed prior to providing the paperwork to our office.

If help is needed, for a $35 fee, all forms can be completed with at least two weeks of time prior to the employer deadline date.

If you would like the forms to be completed within 3 business days, there is a $60 fee.

The fees must be payed to the front office staff at the time they are given to the office staff. Please call the front office to make the payment.

Please understand, this is not a guarantee of approval through your employer.

All forms will be faxed directly to your employer, but a copy can be emailed to you at your request. Please provide a fax number when the forms are brought to our office.

If any information or details will need to be changed after complete, there will be a $10 fee.
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Date of Surgery:
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Date of Surgery:
Date
Year
Month
Day
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Requesting time off from Time through Time .
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Please select one of the following options:
I would like to request the paperwork to be completed by the office and faxed to my employer within 2 weeks. I understand there will be a $35 fee.
I would like to request the paperwork to be completed by the office and faxed to my employer within 3 business days. I understand there will be a $60 fee.
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Is this time including HBO therapy?
YESNO
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When are his treatments scheduled:
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12
Hour
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10
20
30
40
50
Minutes
PM
AM
PM
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Where are the treatments scheduled at?
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Job Description:
Huge
Large
Normal
Small
Ok
Ok
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I, First Name Last Name have read and understand the FMLA/Short term form policy of Hypospadias Specialty Center. I understand that this policy cannot be altered and if I do not agree with the policy, I understand that I may not have the forms completed by the Hypospadias Specialty Center.
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The Person who's requesting the FMLA
First Name
Last Name
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Signature* This field is required.
Clear
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Date* This field is required.
Date
Year
Month
Day
Should be Empty: