Disability / FMLA Form

Disability / FMLA Form Submission

You will need the following to complete your form request:
1. Your form. We do not supply forms. You must get from your employer.
2. Credit card or debit card to pay for the form completion.
3. Know your doctor’s name and the clinic where you were treated.

Patient Details

Patient First Name *

Patient Last Name *

Patient DOB *

Relationship to Patient *

Requester Company Name

Requester First Name

Requester Last Name

Form *

Physician *

Form Type *

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.)

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? *

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 *

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Disability / FMLA Form Submission

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