FMLA Request Form

Patient Request for form completion:

Date requested:*

Date

Patient's name?*

Type of form to be completed? (FMLA, Disability, Unemployment)

Form is for (Please check):

SelfSpouseOther

Other

Name of the person needing form filled out if not patient:

Form type (Please check):

OB/MaternitySurgery/Procedure

If surgery/procedure, please list what the surgery/procedure that was performed:

Type of leave you are requesting*

IntermittentContinuousBoth

Durations requesting (How long are you requesting off?)

Date admitted to the hospital:

Discharge date

Date

Other Relevant facts needed to help fill out paperwork? Please indicated specific dates for leaving and returning to work, if known

Once paperwork is completed, do you prefer:

1. To pick up paperwork?

YesNo

2. Fax paperwork?

YesNo

If yes, what is the fax number?

Form fee for completing paperwork is $35.00 first set of papers filled out, and $20.00 per set after the initial forms completed. Forms will NOT be started until fee is collected by office. Once you have paid the fee please allow 7-10 business days to complete. Please come by or contact the office at 256-241-0885 to make payment.