Disability & FMLA Form

Disability & FMLA Form
Please read and complete the Claimant Information for Disability/FMLA Benefits form in its entirety.

A $20.00 processing fee applies to each disability form request. A $10.00 fee applies to any update to a previously submitted request for disability benefits. We do not charge for the completion of FMLA paperwork.

You may submit this form electronically by clicking “Continue” below. Upon receipt we will request payment via the patient portal. Payments may be made via phone by calling 803-256-4107 option 6.

You may also download a hard copy of the form from our website and submit it to any of our front desk locations with payment.

Payment must be remitted before the form will be processed.

Please allow up to 10 business days for form completion.

Questions related to the status of your request may be submitted via our secure patient portal link (www.midorthoneuro.com) or by calling the number below.

1910 Blanding Street, Columbia, SC 29201

(Ph) 803.256.4107 opt. 6 (Fax) 803.933.6317
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Your Doctor's Name
Body Part Injured
First Date Out of Work

MonthDayYear
Date
Expected Return to Work

MonthDayYear
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Preferred Method

EmailText MessageAutomated Call
Delivery Information

Send me a link for securely downloading my completed form at the notification method specified above.Deliver the completed form to the below (make sure to specify at least one delivery option).
Company Name
Email Address
Fax Number
City
State
Zip
Upload the files from your insurance carrier or employer here:

Cancelof
I authorize Midlands Orthopaedics and Neurosurgery to release all information requested by the company for the processing of my disability claim. I acknowledge this form is valid for one year from the date I sign and may be revoked at any time by providing written notice to our Medical Records / Legal Department.
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Date

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Date
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