Medical Forms and Work Documentation Request

Medical Forms & Work Documentation Request
Use this form to request completion of insurance forms, FMLA paperwork, work restrictions, return-to-work forms, disability forms, and other medical documentation.
Patient & Requester Information
Who is completing this request?
Relationship to patient:

Other
Patient Information
Patient's Full Name

First nameMiddle nameLast name
Patient's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Patient's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email
Personal Representative's Information
Personal Representative's Full Name

First NameMiddle NameLast Name
Organization (if applicable)
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email

Identity Verification
To help protect your privacy and prevent unauthorized release of medical information, please upload a clear photo of a valid government-issued photo ID (such as a driver’s license, state ID, passport, military ID, or other government-issued identification). If you are requesting records on behalf of another individual, please also upload documentation showing your legal authority to make this request.

Please upload or take a clear photo of one of the following government-issued photo IDs:
- Driver’s license
- State-issued identification card
- U.S. passport or passport card
- Military ID
- Permanent resident card (Green Card)
- Tribal identification card
- Foreign passport
- Other government-issued photo identification
For parents/legal guardians requesting records for a minor, please upload both:
- Parent/guardian photo ID
- Documentation establishing authority if needed (examples: birth certificate, guardianship paperwork, court order)
If the request is for an adult represented by another person, please upload both:
- Representative’s photo ID
- Supporting documentation (power of attorney, guardianship paperwork, executor documentation, etc.)
Incomplete or incorrect identifying information or supporting documentation may delay the processing of this form.
Upload Identification

You may upload more than one file. Accepted file types: PDF, DOC, DOCX, JPG, JPEG, PNG, and GIF.
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Request Details
Type of Request

Other
Please describe your request in detail, including any specific dates, restrictions, or information needed.
Employer or Organization Information (if applicable)
Employer/Company Name
Contact Person
Phone Number
Fax Number
E-mail Address
Dates & Time Period Requested
First date affected
Return-to-work date (if applicable)
Upload Forms & Supporting Documents
Please upload any forms that require completion and any supporting documents relevant to your request.

Accepted file formats: PDF, DOC, DOCX, JPG, JPEG, PNG, and GIF
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Mailing and Processing Fee

$10.00 Quantity

Total

Credit Card

Apple Pay

Google Pay

Please Review Before Submitting
- Completion of forms may require provider review and/or an appointment.
- Incomplete submissions may delay processing.
- Submission does not guarantee approval of requested restrictions or leave.
- Most forms can be completed without an administrative fee. However, certain forms that require extensive review, documentation, or preparation may require an administrative fee.
I understand that completion of forms and medical documentation is based on the provider’s medical judgment and review of my medical record.
Requester's Signature
Requester's Name

First NameMiddle NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Hour MinutesAM/PM Option
Should be Empty:

Medical Forms & Work Documentation Request