Instructions for Submitting Your Form

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Instructions

• This site is for patients or their caregivers who need a Disability/FMLA Form completed to apply for disability benefits or employer leave.
• ONLY ONE FORM is permitted per request. For EACH type of form you need completed by the clinic, you MUST upload one form only, pay for it, and submit it online. If you have more than one form to be processed then you will need to submit and pay for each form separately. Three forms - then 3 separate independent online submissions.
• IF YOU UPLOAD MORE THAN ONE FORM PER ONLINE SUBMISSION THEN YOUR FORM SUBMISSION WILL BE REJECTED.
• Completion of new and updated Disability/FMLA Forms can be requested on this site.
• You may choose to have your form processed within 3 business days (expedited) or within 7 business days (standard).
• The standard (7 business day) processing fee for a new Disability/FMLA form is $35 per form. The standard processing fee for a Form Update is $15 per form. The expedited (3 business day) processing fee is $60 per form, regardless of form type. (Note: Workers Compensation forms do not have a processing fee and are processed within 7 days.)
• Pre-payment is required before your Disability/FMLA Form can be processed.
• The processing time begins once we have received all necessary items: prepayment, a completed request/authorization, and the Disability/FMLA Form.
• Once completed, your Disability/FMLA Form will be made available online for you to save, print, or email as needed. You may also ask for your Disability/FMLA Form to be delivered to a third party (such as an insurance company or employer or any party of your choice).
• You will need the following:
  1. A valid driver's license or other valid state-issued ID.
  2. A credit/debit card to make payment
  3. A picture or PDF of your form ready to be uploaded
  4. (Optional) The contact information of the recipient, if you want your completed form sent to a third party (e.g. an employer or insurance company).

Please have these items handy before you start!

To keep you up-to-date, you will receive two text alerts - one to confirm that your request is in process and one to let you know that your request is complete.

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