Short Term Disability/ FMLA Questionnaire
The purpose of this form is to help determine whether the clinical condition is disabling. It is necessary for us to document functional impairment. Please complete the following report as completely as possible. If this form is not completed in the appropriate sections, this may delay benefits.
A person who knowingly files a statement of a claim containing false, incomplete, or misleading information with the intent to injure, defraud, or deceive an insurance company/administrator is committing a fraudulent insurance act, which is a crime. “I certify that the facts, as indicated above, are true and correct to the best of my knowledge.”