Disability/FMLA Intake Form and Authorization

By law, we are required to have a signed authorization from all patients prior to disclosure of their medical information to any outside source.  Most disability or FMLA forms include an authorization to disclose information page or paragraph to be signed by the patient.  If your paperwork contains this, please carefully read and complete that section by signing and dating where indicated and submit along with your forms.

If your forms do not include an authorization page or section, you will be required to sign our office authorization form prior to completion or release of these forms to anyone, including you.  Please note this includes FMLA for your spouse or relative as well.

Below you will find instructions on how to submit our authorization form.  If you have questions about the process please give us a call at (248) 929-9365

There is a $25.00 form fee for completion of all disability and FMLA forms, including forms faxed to our office. 

1. Submit an authorization form online, or download a .pdf version:
   
         Authorization Form

The .pdf version of the authorization form can be submitted by the following methods:

• Fax: 844-598-9633
• Mobile Patient Portal
• In-Person: Drop the completed form off at your doctor’s office

WE DO NOT ACCEPT FORMS VIA MOS INFO EMAIL ON THE WEBSITE.

Please make sure you have completed the authorization in its entirety.  If any required information is left off of the authorization, this could cause a delay in processing.