Disability Form Request
Please Read before filling out the form below:
- Staff member receiving the disability form provides the following to the patient to complete.
- Forms are completed at $25 per form. FMLA forms are $25.00 each form.
- Compliance requires that no form be completed without a dated signature from the patient, below and/or separately in writing.
PER PRACTICE POLICY completion of the form CAN TAKE UP TO 14 BUSINESS DAYS.
THIRD PARTY INSURANCE FORMS (DISABILITY, FMLA, ETC): There is a $25 form fee for completing any form that is not directly related to reimbursement of medical services. For compliance purposes, the patient information portions of the form must be completed and signed prior to acceptance, along with payment. Fees must be paid before forms will be completed. Please allow 7 - 14 days for completion of the forms. Forms can be completed in 24 hours for a $25 Rush Fee. We cannot complete forms at the time of visit.