FMLA - LOA - STD Request
The completion of your Family Medical Leave Act, Leave of Absence, or Short Term Disability, and other forms of this nature, is a courtesy offered to our patients. To ensure that these are filled out accurately, it is necessary that we obtain certain information regarding your leave.
Please enter your name:
Please enter your employer:
Is Leave: (Check the closest match)
Continuous
Intermittent
Both
Leave to begin:
Leave to end:
If intermittent, when is leave to become continuous:
If this is to be picked up, please select your preferred location:
--- Choose Below ---
Marion
Mt. Vernon
Harrisburg
Metropolis
Benton
Fairfield
If you want these faxed, enter the fax number and who to send to the attention of:
Fax:
Attn:
If you want these mailed, enter the address:
Address:
Address:
Preferred contact method:
(Choose one)
Pickup at office
Fax
Mail
Please enter your call-back number (Required)
E-mail address: (Optional)
Has your Employer Faxed this to our office?
?
NO
YES
User Validation Code:
Please enter the validation code above.