FMLA/Disability Paperwork
$30.00 Add to cart

Our practice charges a $30 fee for completing and submitting FMLA or short-term disability paperwork. Please complete the eStore transaction for the fee prior to completing the form below. For questions or issues please email our medical assistants at ma@curryweightloss.com.

FMLA/Short-Term Disability Paperwork

Complete this form in order for your FMLA or short-term disability paperwork to be completed and submitted.

Your Name*
First Last
Your Email*
Enter Email Confirm Email
Date of Birth*
MM slash DD slash YYYY
Phone*
Surgery Date
MM slash DD slash YYYY
Return To Work Date*
MM slash DD slash YYYY
My Job Is*
Employer*
Send Completed Form To Fax/Email:*
Permission To Transmit*
- I give permission to transmit this info via email or fax.
Payment Complete*
- I have completed the $30 FMLA payment.
Upload Scanned FMLA Form Here
Accepted file types: pdf, Max. file size: 50 MB.
If we haven't already received it, upload a PDF of your form here, or fax it to 513-559-1235.
Additional Information
By clicking the "Submit" button I give permission for this information to be transmitted via internet to JourneyLite Physicians.
Email
This field is for validation purposes and should be left unchanged.

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FMLA & Short-Term Disability

FMLA/Disability Paperwork

FMLA/Short-Term Disability Paperwork

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FMLA/Disability Paperwork

FMLA/Short-Term Disability Paperwork