Get Form Completion Request (disability/fmla) Worksheet ... - Info Kaiserpermanente

The FORM COMPLETION REQUEST (Disability/FMLA) Worksheet is a vital document for individuals seeking disability or Family and Medical Leave Act (FMLA) benefits. This guide provides a clear, step-by-step approach to filling out the form accurately and efficiently.

Follow the steps to complete your form with ease.

1. Press the ‘Get Form’ button to access the worksheet and open it in your preferred editor.
2. Begin filling out the patient information section. Include the patient's full name, date of birth, health record number, and mailing address. Indicate whether it is acceptable to leave a detailed phone message.
3. If requesting information on behalf of a family member, complete the section with your name and relationship to the patient.
4. Select your preferred method of form delivery from the options: mail, email, pick up, or fax. Provide the necessary contact details depending on your selected method.
5. Describe the condition or injury the patient is experiencing, including the estimated date of onset.
6. In the work status history section, fill out details regarding time loss related to the patient's condition and specify the employer's name and the clinician authorizing the time loss.
7. Indicate the nature of the patient's work activity and record the time loss experienced in days and hours within the last three months.
8. Choose whether this is a recertification or a new request and provide an estimate for time loss needed.
9. Complete the continuous, modified duty, or long-term disability sections as applicable, including necessary modification details and expected duration.
10. Review all sections for accuracy and completeness. Once satisfied, either save your changes, download, print, or share the completed form depending on your needs.

Complete your FORM COMPLETION REQUEST (Disability/FMLA) Worksheet online today.