Disability/FMLA Request

New Patient Forms - Referral & Medical Request Forms
Home / Patient Information / Patient Forms / Disability/FMLA Request Form

Disability/FMLA Request Form

  • To submit a Disability/FMLA request, please click here.
  • Do not submit your forms in person.
  • Please make sure that you have your disability or FMLA form from your employer or carrier before logging in. No forms are provided on this link.
  • Normal turnaround time to receive your completed form is 5 business days.
  • There is a $30 cost per form, $15 per updated form, and $50 for an expedited request (guaranteed 3 day turnaround).
  • FMLA and Disability forms cannot be submitted on the same request. These forms must be submitted separately.
  • If you have any questions, please call (912) 231‑4626.
Upload & Process FMLA or Disability Form