FMLA/STD Patient Intake & Authorization

FMLA / STD Patient Intake and Authorizations
Welcome!

Complete your patient details, authorize the release of your health information, and upload the required forms and identification.

Before you begin, please have the following ready:
- The form you need completed (FMLA, disability, school, or other medical-related forms)
- A valid photo ID
- A credit or debit card for payment
This request process is for patients and authorized caregivers. Please allow 7–10 business days for your forms to be completed. If you have any questions, please contact us at SOSFMLA@SOUTHWESTORTHO.COM.

Thank You for choosing Southwest Orthopaedic Specialist for all your healthcare needs.
Service Selection
Warning: If you switch the form to Spanish, the patient must still complete the form in English for completion of the forms.
Patient Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is this leave for your own medical condition or to care for a family member?
Family Member Name
If you select "Care for a family member," you must upload proof of care documentation (for example, a marriage license or other documentation showing the caregiving relationship).
Proof of Care Documentation

Upload proof of caregiving relationship.
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Patient Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address (Your completed forms will be sent back to the email address your provide below. Please make sure it is entered correctly.)
example@example.com
Clinic Location
Physician
Patient Occupation / Job Title
Requested Start Date (Leave/Disability)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Leave / Disability (Brief Description)
AUTHORIZATION TO RELEASE HEALTH INFORMATION
Southwest Orthopaedic Specialists is authorized to release health information as described in this form, for the purpose of completing and submitting FMLA, Short-Term Disability (STD), or other health-related forms at my request.
Information is to be released to (Name/Organization)
Patient Employer / Company Name
Recipient Address
The following types of records may be released for all dates of service: Completed form(s); Supporting documentation, which may include Office Visit Notes, Operation/Surgery Notes, Nursing Notes, and other diagnostic and treatment records. Please review and authorize disclosure of all categories:
Categories Authorized for Release
If I authorize the release of HIV-related, alcohol or drug treatment (SUD), or mental health treatment information, the recipient may not release it to additional recipients unless permitted to do so under Federal or State law. Federal law protecting SUD records (42 CFR Part 2) prohibits unauthorized use or disclosure of these records.
I Understand That:
The person or organization receiving this health information may not be required by Federal privacy laws to protect it and may share it with others if permitted by laws governing them. This authorization is valid for one (1) year from the signature date, unless I cancel it earlier. I may cancel this request with written notification to my Provider, but it will not affect any information released prior to notification of cancellation. My Provider may not condition treatment, payment, enrollment in a health plan, or eligibility for benefits on whether I sign this authorization.
By electronically signing below, I understand and agree to the following: (1) I am the individual identified as the patient above or am legally authorized to sign on behalf of the patient; (2) I agree to conduct business with my Provider electronically; (3) I may request a copy of this signed document by downloading a copy from the confirmation page or by contacting my Provider after signing; and (4) I understand that my electronic signature carries the same legal effect as a handwritten signature.
ROI Signature
Relationship to Patient
If you are signing on behalf of someone else, you must provide documentation showing that you are legally authorized to act on their behalf. Please upload this documentation with your request; forms cannot be completed without it.
Uploads
Upload the form you would like filled out. Please make sure: Upload one PDF file, up to 20 MB. This is the form that will be completed and sent for delivery. Before uploading, make sure all pages are included (front and back if applicable), all pages are legible and right side up, multiple pages are combined into one PDF, and the file is not password protected. Uploading separate files or a file that needs correction may result in additional fees.
Upload Completed FMLA or Disability Form

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Upload Driver's License / Photo ID

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Payment

Please complete payment for submission processing and related documents.

Submission Processing Fee

New FMLA \/ STD Form Submission

This is to be used for the request of new FMLA / STD forms to be completed.

$45.00 Quantity

Follow Up FMLA \/ STD Form or Additional Information Needed

This is to be used when FMLA / STD Forms have already been completed by our office for the same medical condition and now an update to the form or additional information is needed. IF YOU ARE SUBMITTING A NEW REQUEST FOR FORMS, YOU MUST SELECT THE NEW FMLA / STD FORM SUBMISSION FOR COMPLETION OF YOUR FORMS.

$30.00 Quantity

Total

Debit or Credit Card
Credit Card Number	Security Code
Expiration Month	Expiration Year

Signature
Should be Empty:

FMLA / STD Patient Intake and Authorizations

Uploads

Payment

Submission Processing Fee*

Submission Processing Fee