What dates are you requesting to be out of work?
We will NOT decide these dates for you. If unsure, please discuss these dates with your employer and/or physician.
Please Note: If you change the dates above after your disability forms have been submitted, you may be subject to pay an additional fee. Please discuss any dates with your employer prior to submitting your forms.
By signing this form, you are agreeing to allow Academy Orthopedics, LLC to release your medical information to your insurance company for the purpose of disability reimbursement and or Family Medical Leave.