• Form Completion Request

    This site is for patients or their caregivers to request Disability, FMLA or other forms be completed in relation to disability benefits, employer leave or other medical need.

  • Please read all of the information & instructions below:

    1. Turnaround time for all forms is 7-10 business days with no exceptions. Only one form/packet is permitted per request.

    2. ZoeRVA Health providers require that clients are compliant with their treatment plan AND that care has been established for at least 6 months before considering completing documentation. After a period of 6 months, form completion is at the discretion of the provider. Do NOT submit a form for completion without FIRST discussing with your provider. (If you have not discussed the completion of this form with your provider, please reach out directly via your patient portal or call the office to schedule an appointment.)

    3. Complete all of the required information fields with as much detail as possible.

    4. Upload your form in PDF format, if possible. Photos of your form will not be accepted for completion if they are not clear. Do NOT upload a form that has not been previously discussed with your provider.

    5. Pre-payment is required for your form to be processed. A delay in payment may lead to a delay in turnaround time.  Do NOT submit payment for a form that has not been previously discussed with your provider.

    • $100 for FMLA Forms
    • $200 for Disability Forms
    • $75 for Other Forms
    • $50 for a continuation or update to a current form
    • Note: There are no Form Fees for Workers' Compensation or patients with Medicaid coverage. Coverage will be verified prior to form completion.

    6. If your form is denied by your provider, you will be refunded the amount paid for its completion.

  • To proceed you will need the following:

    • A valid driver's license or other valid state-issued ID
    • A credit/debit card to make payment, if applicable
    • A PDF, scan or photo of your form ready to be uploaded
    • The contact information of the recipient, for forms being sent to a third party, such as an employer or insurance company

  • PATIENT & FORM DETAILS

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Select Health Insurance Type*
  • This form is for...*
  • This request is for...*
  • Please identify the first date out of work:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • What is the anticipated return-to-work date?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • What is the date of your next appointment with the above selected provider?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Has there been an admission to the hospital for the medical issue related to this form?*
  • Hospital Admission Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Hospital Discharge Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • DELIVERY DETAILS: Once completed, you will be notified via a patient portal message, and your form will be available to access there.

    Please indicate below if your form should be sent to an optional third party.
  • Does your form need to be sent to a third party, such as an employer or insurer by fax?*

  • THIRD PARTY DELIVERY INFORMATION:

  • As the patient/caregiver, you will be provided with online access to your completed form when it is ready.  We will notify you via secure message through your patient portal. 

    PLEASE VERIFY THAT YOUR PATIENT PORTAL IS CURRENTLY ACTIVE AND YOU ARE ABLE TO LOG IN.  Reach out to the office if you need a new portal link.

    If you want your completed form to be delivered to someone else (such as an employer or insurance company), you are solely responsible for the following: 

    • Choosing the option to deliver to a person/third party at the time you place your online form completion request. 
    • Providing accurate fax delivery information at the time you place your online request. 
    • Ensuring that the delivery information you provide is completely correct. 
    • Confirming the receipt of the completed form by the person/third party you have designated. 

    *We will only make one attempt to deliver by fax.

    ZOERVA IS NOT RESPONSIBLE FOR ANY DENIAL OF BENEFITS DUE TO THE FAILURE OF THE PATIENT/PATIENT CAREGIVER TO CONFIRM TIMELY RECEIPT OF THE COMPLETED FORM BY THE DESIGNATED PERSON/THIRD PARTY.

  • Format: (000) 000-0000.

  • UPLOADING YOUR FORM:

  • *NOTE: Before submitting your form to us, please be sure to fill out all sections that you, as the patient or caregiver, are required to fill out.  If those sections are not complete, we cannot begin processing your form.

  • Please select how your form is formatted below.*

  • You must review the pictures/scans to ensure acceptable image quality. Staff will type directly onto the form pages you supply.

    INSTRUCTIONS FOR TAKING PICTURE(S):

    1. Page(s) should face the right direction (not upside down or sideways)
    2. Page(s) should lie flat (smooth out any folds/creases in page)
    3. Picture should be taken from above, straight down
    4. Avoid as much shadow as possible
    5. Avoid as much background (table, furniture, leg, etc.) as possible
    6. If your page(s) are turned the wrong direction, bent, unclear, etc., you will be contacted by text to submit new pictures. This will delay the processing of your form!

  • Image field 13
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  • Consent to Electronic Submission and Processing

  • I understand that by submitting this form electronically, I am providing personal and health information to ZoeRVA Health so that my request can be reviewed and processed.

    I understand that the practice utilizes third-party technology vendors to collect, transmit, store, and manage information submitted through this form.

    I authorize the practice and its service providers to receive and process the information I submit for the purpose of responding to my request and completing any requested forms or documentation.

    I understand that reasonable safeguards are used to protect my information, but that electronic transmission and storage of information carries some inherent risk.

  • PAYMENT & SUBMISSION:

    Please review the fee amount below and, if applicable, enter your credit card information for payment. Click "Submit Form Request" below to complete your request and send your form for processing. *Payment amount is determined by the type of requested form.

  • NO PAYMENT REQUIRED, PROCEED TO SUBMIT.

  • Payment Amount $*

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    USD
    Debit or Credit Card
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