FMLA/Form Request

FMLA/Disability Form Request
Patient Name (First and Last)*
Date of Birth*

MonthDayYear
Date
If the forms are not for the patient, please indicate the name of the person
- Please note there is a processing fee of $20 for each form. (Since you are submitting FMLA online, please note a staff member will contact you 24-48 business hours after form is submitted to collect payment. Or you can call the office at (517) 618-9507 to the receptionist to make that payment.)
- The form is typically completed within 7-10 business days from payment date.
- Please be sure you have completed the "patient" portion of your form prior to submitting.
- Forms are completed for medically indicated time off work ONLY. Any additional time that you are eligible for FMLA must be coordinated by you and your employer.
- Please NOTE: Some requests for FMLA may require an appointment.
Please complete this questionnaire and your answers will be taken into consideration when our staff completes your paperwork for your employer.
What type of leave are you requesting?

IntermittentContinuousUnsureA form to be completed other than leave
Have you stopped working? If so, please indicate the date

MonthDayYear
Date
What dates are you requesting leave for?
From

MonthDayYear
Date
To

MonthDayYear
Date
What is the condition(s) you are requesting leave for or what are these forms in regards to? (be specific in order of most relevant)*
How would you like these to get back to your employer?*

FaxMailPickupOriginal forms required
If chose fax or mail, please indicate where we are sending.
Please upload PDF forms below once your portion of the paperwork is completed. (Photographed images of paperwork are not accepted.)

Cancelof
PLEASE READ:

By signing below, I authorize this Avenue Health to disclose relevant medical information, as permitted under HIPAA, to my employer and/or designated third-party administrator for the purpose of processing my FMLA and/or short-term disability request. I understand that only the minimum necessary information required to support my request will be released. I further acknowledge that any additional medical documentation requested by my employer or third-party administrator, including verification of medical conditions, is subject to the terms and requirements set forth by my employer, and that my signature indicates my agreement with those terms.
Patient Signature:*

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FMLA/Disability Form Request