FMLA/Disability Form

FMLA / Disability Form

The fee for all initial FMLA Disability/Return to work/Physician Statements is $50.00. If additional forms/statements are required, they will incur an additional $50.00 charge per form. Payments can be made in the office or they can be completed via our website. Please allow 10-14 days for completion.

Patient Name(Required)

First Last

Date of Birth(Required)

Phone Number(Required)

Forms are for(Required)

Self

Family Member

Select One(Required)

Fax

Mail

Office Pick-Up (Main)

Office Pick-Up (Crestwood)

Fax Number or Address to Send Forms(Required)

Select One(Required)

Maternity FMLA/Disability

GYN Surgery FMLA/Disability

Select One(Required)

Vaginal Delivery

C-Section

We can only medically cover you for 6 weeks.

We can only medically cover you for 8 weeks.

Due/Delivery Date(Required)

Surgery Date(Required)

Date Leave Ends(Required)

I authorize Tennessee Valley OB-GYN to release my FMLA/Disability/Return to Work/Physician Statement to:

Name of Organization or Individual(Required)

Today's Date(Required)

Patient Signature(Required)

Main Office 910 Adams St. Suite 200
Huntsville, AL 35801 (256) 888-9343

Crestwood Office 1 Hospital Dr. SW Suite 302
Huntsville, AL 35801 (256) 964-8947

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