Disability/FMLA Form

Patient Information:
Full Name:*
DOB:*
MM slash DD slash YYYY
SSN (last 4 digits):*
Address:*
Street Address City State ZIP Code
Phone #:*
Email Address:*
Release Information to:
Name of Person/Organization:*

(Example: Employer, Disability Carrier, Auto Carrier, etc.)
Phone:
Please check one:*
- Mail to Address
- Fax #
- Call to Pick Up
Mail to Address:*
Street Address City State ZIP Code
Fax #:*
Phone #:*
Treating physician's name:*
Time off is:*
- Intermittent
- Continuous
Additional information:
If you DO NOT want certain portions of your medical records released, please check the categories listed below you would like excluded.
- Substance Abuse, if any
- AIDS/HIV/STDs, if any
- Psychological/Psychiatric conditions, if any
Signature:
I hereby authorize Michigan Orthopaedic Surgeons, PLLC and its affiliates to release or disclose to the person(s) or organization 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 1 year from the date of signature. I understand that I may cancel this request with written notification but that it will not affect any information released prior to notification cancellation. I understand that the information used or disclosed may be subject to re-disclosure by the recipient on this request and therefore the privacy of personal and health information is no longer protected by HIPAA. I acknowledge that Michigan Orthopaedic Surgeons, PLLC or its affiliates reserve the right to charge for processing and copying information.
Signature*
Patient, parent of minor, legal guardian, personal representative or person with authority
Date:*
MM slash DD slash YYYY
Name and Relationship (if other than patient):
Comments
This field is for validation purposes and should be left unchanged.

Disability/FMLA Form

Patient Information:

Release Information to:

Additional information:

Signature: