Disability / FMLA Form Submission Synergy Orthopedics has developed this process to ensure a precise and secure method for submitting Disability and FMLA forms. This is crucial because it protects sensitive patient information and makes accessing medical leave benefits much more efficient. You will need the following to complete your form request: 1. Make sure to have your disability or FMLA form with you BEFORE logging in. (You should have received these forms from your disability carrier or employer). No forms are provided on this link. 2. FMLA and Disability forms cannot be completed on the same request. These forms must be submitted separately. Once the form is completed and payment is received, the form will be emailed or mailed to you. The cost is a flat $50.00 per form, $25.00 for an updated form, $100.00 for an expedited form request. The turnaround time for medical records can take up to five business days. Patient Details Patient First Name * Patient Last Name * Patient DOB * Relationship to Patient * SelfSpouseParentGuardianOther Requester Company Name Requester First Name Requester Last Name Form * Short Term DisabilityLong Term DisabilityFMLAOther Physician * Select a PhysicianAndromahi Trivellas, MDDaniel S. Brereton, DODavid J. Burnikel, MDEnoch Chang, MDEric K. Lizerbram, MDEric P. Hofmeister, MDFelix Shall-Gin Wong, MDGavin Kolodge, DOGordon C. Zink-Brody, MDGregory S. Anderson, MDHarbinder S. Chadha, MDJames A. Cooper, MDJerrick Robker, DOJohn A. Grotting, MDJonathan J. Myer, MDM. Lucius Pomerantz, MDMark T. Selecky, MDMatthew C. Shillito, MDMatthew Follett, MDMichael A. Sirota, MDMichael Muldoon, MDMichael R. Lenihan, MDPascual Dutton, MDRina Jain, MDSam Klatman, MDScot A. Youngblood, MDTal S. David, MDThomas Hong, MD Form Type * NewUpdateExpedited If applicable, what was/is your first day OFF work? If applicable, what is your return to work date? Are you requesting intermittent leave? (Intermittent means occurring at irregular intervals, not continuous or steady.) Not ApplicableYesNo Cell Phone Number * Additional information you would like to add to aid in the completion of your form Email Address * How should we communicate with you? * EmailPhoneText I am authorizing Synergy Orthopedic Specialists, Inc. and its affiliates to release or disclose the medical information listed above. All medical records requested, including any specially protected records such as those relating to psychological or psychiatric impairments, drug abuse, alcoholism, sickle cell anemia, or HIV infection, unless otherwise noted. This authorization is valid for 12 months from the date of signature. I understand that I may cancel this request by providing you with written notification; however, this cancellation will not affect any information released before receipt of this notification. I understand that the information used or disclosed may be subject to re-disclosure by the recipient listed above and will no longer be protected by federal regulations. I know that I have the right to refuse to sign this authorization, and my healthcare provider may not condition treatment on my signature. Signature * Upload Your Form for Completion * + Add New Reset
