Forms, Letters, and Reports Request

Before You Begin

Please read carefully.

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Patient Name* This field is required.Enter FULL legal name as you wish for it to appear on the form/letter.

First Name

Last Name

Patient Phone Number* This field is required.

Please enter a valid phone number.

Contact Email* This field is required.Your submission confirmation will be directed to this email.

example@example.com

What type of documentation are you requesting?* This field is required.

Excused Absence for Medical Visit

Confirmation of Care Letter

Return to Work / School Letter

Temporary Leave of Absence Letter (up to 2 weeks)

Medical clearance letter for outpatient treatments

Clinical notes for fitness for irreversible surgeries, procedures or deployment

Jury Duty Excuse Letter and/or Form

ADA Accommodations Letter and/or Form (School)

ADA Accommodations Letter and/or Form (Work)

Short Term Disability Application

FMLA Application

FAA Psych Evaluation Report

VA Disability Nexus Letter

Other

For which date(s) of visits are you needing an excused absence letter?

Date

What details are you needing the confirmation of care letter?

Date of establishing care

Last visit date

Frequency of visits

Diagnoses

Treatments

Medications

Have you discussed the request directly with your provider?

Yes, I have already discussed it with my provider.

No, I have not discussed it with my provider yet.

We advise you to wait until your next scheduled visit to discuss this request with your provider. If you need this request completed sooner than your next visit, please proceed and the Patient Success Team will coordinate with your provider to determine if that they are able to complete your request.

CONTINUENOT INTERESTED

Have you reviewed the fees and delivery times associated with this request?Review fees and expected delivery times here.

CONTINUENOT INTERESTED

Upload forms or any supporting documentation you have to complete your request.Review typical documentation needed for various requests here.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Explain your current academic environment and learning challenges.(E.g. sophmore in college, difficulty staying on task long projects due to ADHD)

Offer specifics on accommodations requested.(E.g. extended testing time, extensions on deadlines, quiet environment, etc)

Explain your job role and current challenges.(E.g. customer service rep in a loud and noisy office finding it diffucult to focus on sales calls due to ADHD)

Offer specifics on accommodations requested.(E.g. hours restriction, working from home, relocating office/cubicle to a different area, how many days of the week)

Add any additional details that may be helpful to the completion of your request.

Thank you for your inquiry. You may close out of this window without needing to submit this form. Have a nice day.

You can now click the Review and Submit button. Our office will contact you within 48 hours. Please visit OnPatient for any additional questions. Thank You.

Forms, Letters, and Reports Request