FMLA/Disability Form Completion
Patient Authorization
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Deliver Forms to:
*
Patient Email
Third Party
Third Party Name (for example, disability company):
Third Party Fax or Email:
Authorization
*
I Authorize "Complete My Form" to release medical information to insurance carriers regarding disability claims.
Payment Preference:
PayPal
Credit/Debit/Apple Pay (Stripe Checkout)
Venmo
PayPal ID
Venmo ID
Acknowledgements:
*
By signing this authorization, my treatment, payment, benefit enrollment or eligibility are not effected.
I may revoke this authorization but this will not effect actions taken prior to revocation.
If the receiver is not a health plan or provider, the information released may not be protected under federal privacy regulations.
I may request a copy of this form after I sign and date it.
I understand there is a fee of $25 for form completion due before forms are delivered.
Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: