Medical Letter Request or Paperwork
Manager and Doctor will Full-fill All requests
Please Note:
To request a letter from our practice, you must adhere to your treatment plan. Our clinicians reserve the right to deny any request for medical letters or paperwork for clinical reasons, regardless of the patient's request. Please note that the fee for this service is nonrefundable. Additionally, paying the fee does not guarantee that the requested letter or medical paperwork will be provided. (3-5 business days).
Charges
Every Letter has a $50 surcharge or FMLA request or Disability Paperwork
Service Charge
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Letter Request Charge
$
50.00
Quantity
1
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10
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
Patient Name
*
First Name
Last Name
Date of Birth:
*
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Month
-
Day
Year
Date
Patient Email:
*
We Will send letter to Email and Upload to your Chart in your portal and email a copy
Type of Letter (1-3 Business days for Every Request)
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FMLA Request For Patient
FMLA Request for Family Member or Caretaker
Letter for Medical Excuse for Work
Letter for Medical Excuse for School
Letter for Return to Work
Letter for Return to School
Letter for Jury Duty for Medical and Emotional issues
Letter for Emotional Support Animal
Letter for Academic Medical Leave from College
Need School Accommodation for Attention and Focus issues
Require Hospitalization for Relapse of Symptoms
Require Partial Hospitalization for Relapse of Symptoms
Need Letter for School Accommodation to Administer A Medication at School
Short-Term Disability with Need for Medical Excuse from Employment
Other
Pick what issue your having to Consider FMLA (If needed, briefly describe other appropriate medical facts related to the condition(s) for which the employee seeks FMLA leave.)
*
Relapse or Start of Depression causing Functional impairment
Relapse or Start of Depression and Anxiety causing Functional impairment
Relapse or Start of Panic Attacks causing Functional impairment
Relapse or Start of Anxiety and Obsessive symptoms causing Functional impairment
Relapse or Start of Mood Swings causing Functional impairment
Need for FMLA (Max duration is 12 weeks):
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Due to the condition, it is medically necessary for the employee to work a reduced schedule
Due to the condition, it is medically necessary for the employee incapacitated for a continuous period of time
Due to the condition, it is medically necessary for the employee to work a reduced schedule
Due to the condition, it is medically necessary for the Family Member or Caretaker to be absent for a continuous period of time
Due to the condition, it is medically necessary for the Family Member or Caretaker to be absent from work on an intermittent basis (periodically), including for any episodes of incapacity i.e., episodic flare-ups.
Due to the condition, it is medically necessary for the Family Member or Caretaker to work a reduced schedule
State the approximate date the condition started or will start:
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Month
-
Day
Year
Due to the condition, the employee to perform one or more of the essential job function(s). Identify at least one essential job function the employee is not able to perform:
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Pick what issue your having to Consider Short-Term Disability with Need for Medical Excuse from Employment
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Relapse or Start of Depression causing Functional impairment
Relapse or Start of Depression and Anxiety causing Functional impairment
Relapse or Start of Panic Attacks causing Functional impairment
Relapse or Start of Anxiety and Obsessive symptoms causing Functional impairment
Relapse or Start of Mood Swings causing Functional impairment
Pick issues Supporting Letter for Emotional Support Animal
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Depression and Anxiety
Depression
Panic Attacks
Anxiety and Obsessive symptoms
Require Partial Hospitalization for Relapse of Symptoms
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Depression and Anxiety
Depression
Panic Attacks
Anxiety and Obsessive symptoms
Mood Swings
Mania
Hypomanic Symtoms
Require Hospitalization for Relapse of Symptoms
*
Depression and Anxiety with Hopeless Thoughts and Suicidal issues
Depression with Hopeless Thoughts and Suicidal issues
Panic Attacks with Hopeless Thoughts and Suicidal issues
Anxiety and Obsessive symptoms with Hopeless Thoughts and Suicidal issues
Manic symptoms
Psychotic Symptoms
Mood Swings
Pick issues Supporting Letter for Medical Leave from College
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Relapse or Start of Depression and Anxiety causing Functional impairment
Relapse or Start of Depression causing Functional impairment
Relapse or Start of Panic Attacks causing Functional impairment
Relapse or Start of Anxiety and Obsessive symptoms causing Functional impairment
Name the Medication Needed to be administered During School
*
For Example Prozac etc.
Describe Details for the Letter or Request (Be Specific and include dates if needed):
*
All Letters and Paperwork are Billed to your Insurance
Upload any supporting documents (optional)
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