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.

Name *
Name
Work Status
Please describe in detail.
If yes, please explain.
If yes, please explain.
Please list all medications, dosage, and frequency.
Are you under the care of another medical practitioner? *
If so, please furnish the name(s) and telephone number(s):
If so, please furnish the name(s) and telephone number(s):
Office Phone
Office Phone
Office Phone
Office Phone

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.”