Request to complete FMLA paperwork

Request to complete FMLA paperwork

Purpose: This form is used to request your provider to complete FMLA Paoerwork. Make sure to review our FMLA paperwork policy and fees associated with it
Section 1: Patient Information
Patient Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Section 2: Guardian Information

Enter Information of Guardian who is applying for FMLA
Guardian's Name*

First NameLast Name
Relationship to Patient: *
Section 3: Reason FMLA is Required

Please explanation the reason for FMLA request
Section 4: Acknowledgement & Agreement
I have reviewed MindWeal's policy on FMLA eligibility and I believ that I am eligible for FMLA on the basis of my child's mental health needsI have reviewed MindWeal's document processing policy outlining the charges associated with processing of FMLA paperwork
Should be Empty:

Section 1: Patient Information