FMLA/Work Release/ Return To Work

FMLA/ Short Term Disability/ Work Release Request
By submitting this electronic request form you are authorizing A Personal Choice to complete Famliy Medical Leave Act (FMLA), Short Term Disability, or Return to Work forms and send these completed forms to you or, if required, your employer.

After you pay the required records fee and click "Submit", our office will recieve your request. This fee is required for any form your employer requires.

Your forms will be completed within 72 hours (three business days) of your post-operative visit.

You will be notified by email when your release forms have been completed.
The maximum amount of leave approval for a tubal ligation reversal or Essure reversal/removal patient is four (4) weeks.

The maximum amount of leave approval for a vasectomy reversal patient is three (3) weeks.
When would you like to return to work?*

MonthDayYear
Date
Sending Records To You
We will send you a copy of the completed forms. What is the best email address to use?*

Confirmation Emailexample@example.com
All records will be password protected with the year of your birth.

For example, if you birth date was March 1st 1980, then we will password protect your records with the password of "1980".
What is the best number to reach you if we have questions about your request?*
Please enter a valid phone number.
Do you have any comments or instructions for our staff?
I understand completion of FMLA, disability, or return to work release forms will require a $35 fee.*

I understand
Emailed documents will be sent in a PDF format and will be password protected with the year of your birth. If you were born May 1st 1980... your password will be "1980."*

I understand
Some employers will require your release forms be sent directly to them from our office. If your employer requires us to send records do we have your permission?*

You have my permission to send my release forms directly to my employer if my employer requires the release directly from A Personal Choice.No. You can not send my release to my employer
Confirmation of Employer Release Hold: Please confirm you are not allowing us to send your release forms to you employer by typing in all capital letters "DO NOT SEND MY RELEASE TO MY EMPLOYER"*
Some employers will require your medical records regarding your health care treatment at A Personal Choice. If this information is required by your employer do we have your permission to send a copy of your medical records to your employer? This may include your complete medical and surgical history, signed consents, lab work, your operative report, post-operative office evaluation, and post-operative treatment.*

You have my permission to send my medical records directly to my employerNo. You can not send my medical records to my employer
Confirmation of Employer Medical Records Hold: Please confirm you are not allowing us to send medical records to your employer by typing in all capital letters "DO NOT SEND MY MEDICAL RECORDS TO MY EMPLOYER"*
Enter your name as it appears on your records at our facility*

First NameMiddle NameLast Name
Enter your date of birth:*

MonthDayYear
Date
How would you like to get your forms to us?*

I will upload my forms electronically to this request.I will bring my forms with me to my consultation.I will email forms to your office before my visit.I will email forms to your office after my visit.
Please upload your FMLA, disability, or return to work forms here:*

Cancelof
Release forms emailed to our office should be sent to:

SchedulingNurses@tubal-reversal.net
Please indicate you understand and agree to each of the items below.
I understand I have the right to withdraw my authorization at any time except to the extent that action has already been taken pursuant to this authorization. I understand if I revoke this authorization, I must do so in writing and present my written revocation to A Personal Choice.*

I understand and agree
I understand authorizing the disclosure of this health information is voluntary. I can refuse to sign and future treatment, payment, or eligibility for benefits will not be based on whether or not I provide authorization for the requested use or disclosure. I understand the recipient may be prohibited from disclosing substance abuse information. I understand I may inspect or copy the information to be disclosed.*

I understand and agree
I understand information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient of the information and is no longer protected by federal confidentiality laws.*

I understand and agree
Unless otherwise revoked, this authorization will expire six months from the date of the signature listed below.*

I understand and agree
What is the reason for the release of your medical records?*
I understand A Personal Choice will email my release directly to me.*

I understand
I understand A Personal Choice will ONLY email my release to my employer only if my employer REQUIRES the release be sent DIRECTLY from A Personal Choice .*

I understand
Patient signature*

Clear
Date*

MonthDayYear
Date
A 3.99% card processing fee is added to all credit, health savings account, and flexible spending account card transactions.

FMLA, Disability, Work Release Fee*

FMLA, Disability, Work Release Fee

$36.40

Enter coupon

Total

$0.00

Credit Card

Is the credit card being used to submit this form in the patient's name or another person's name?*

This credit card is in my name (the patient)This credit card is in another person's name (someone who is not the patient)?
What is the name of the person on the credit card being used to pay the scheduling fee and submit this form?*

First NameLast Name
Staff Documentation of Records Release

Always send patients a password protected PDF copy of completed records
Completed forms were sent to:*

Patient by email address listed abovePatient's employer
How were records sent?*

Emailed to patient using email address aboveFaxed to employerEmailed to employer
Employer fax number forms were faxed to:
Please enter a valid phone number.
Employer email address forms were emailed to:
example@example.com
Patient notified by*

EmailOther
Date records were sent*

MonthDayYear
Date
Staff member's name:*
Staff member's signature:*

Clear
Date*

MonthDayYear
Date
1. Save this form in patient's electronic medical chart.

2. Archive this form when completed.

3. Save completed release to patient's electronic medical chart.

4. If release has been sent to employer then notify patient task has been completed.
Should be Empty:

FMLA/ Short Term Disability/ Work Release Request

Sending Records To You

Credit Card

Staff Documentation of Records Release