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.
- We are unable to submit forms in which only the "physician/provider"section is filled out. This will delay processing. 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? Indicate fax, mailing address, or email below. You may select more than one. (Once completed, you'll be notified by our staff)*

FaxMailEmailPickupOriginal forms required
Please indicate information above if you chose fax, mail, or email.
If you have PDF forms to upload, please attach here.

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FMLA/Disability Form Request