FORMS COMPLETION POLICY AND QUESTIONNAIRE

Patient Name:

Chart #:

S.S. #:

DOB:

Leon W. Lewis MD., P.C. will provide an excuse due to medical illness with specified dates at no charge during a clinic visit.

If further information is requested such as completion of a FMLA, SHORT-TERM DISABILITY, or LONG-TERM DISABILITY form a processing fee will be charged. The fee cannot be billed to your insurance company. Filling out forms requires careful consideration and a considerable amount of our time and goes beyond routine medical care.

Understand that if your form does not include a signed medical release, you will be required to complete our Authorization to Use or Disclose Medical Information.
Allow seven to ten business days (7-10) for the completion of any form.
Leave all sections to be completed by the healthcare provider blank. If you improperly complete a form, it may cause delays and / or we may request a new form from you.
Let us know if you would like your form or letter faxed, mailed or picked up in person.
Processing fee is $25 per form and must be paid before form is completed.
Expedite Fee is an additional $5.00 per form (completed within 24 to 48 hours)
Notary Public fee (when necessary) is $10.00 per form

Request:

FMLA Disability Letter Other (specify):

Return to:

Patient Facility Provider Other :

Fax to Company Attention:

Fax#

Mail to Company Address:

Fax or Mail to Patient:

I or my HIPPA designated person will pick it up the form within 30 days (forms will be destroyed after 90 days).

I hereby authorize Leon W. Lewis MD., P.C. to disclose my medical information as requested. Information used or disclosed by this authorization may be subject to subsequent disclosure by the recipient and is no longer protected by this rule.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient or Designated Representative Signature:

Date:

Received by:

Date:

Completed by:

Date:

QUESTIONNAIRE - FMLA, SHORT-TERM AND LONG-TERM DISABILITY FORMS

Please fill out the following questions and be as specific as possible. Use additional paper if needed.

Print Name:

Date:

1) Does the medical condition involve you or a family member? If pertaining to a family member, provide his or her name and primary care provider.

2) Describe the medical facts, including specific diagnosis, symptoms, and regimen of continuing treatment for the serious medical condition. BE SPECIFIC.

3) Name of the physician and date of the first office visit for this serious medical condition(s):

PHYSICIAN:

DATE OF INITIAL DIAGNOSIS:

4) Names of the physicians and dates of all visits, treatments, hospitalization, for the serious medical condition:

5) Dates of work missed due to incapacity of the serious medical condition:

6) Explain your job duties and responsibilities and why you cannot work. If applicable, give explanations of how treatment and/or medication for your serious condition impact your ability to work as well.

7) When do you anticipate to stop working full time?

8) When do you anticipate returning to work full time: If you are returning to work with “restrictions” or “limited” to perform your regular duties, please explain in Detail, why you cannot perform those “limited” duties.

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