Disability and FMLA
IMPORTANT INFORMATION REGARDING
DISABILITY INSURANCE BENEFITS FORMS, FMLA FORMS, ETC.
We charge an administrative fee for the completion of certain work or insurance related documents presented by patients. These documents include disability insurance benefit forms, Family and Medical Leave Act (FMLA) forms and insurance forms for health and life insurance. Typically, your employer or insurance company requires these forms when a medical condition prevents your from reporting to work. A licensed medical professional must sign these documents verifying that the medical information is correct. We will be happy to assist you in providing this information. The fee for this service is $25 per document.
Please follow these steps to ensure the successful and timely completion of your forms:
- Obtain a copy of the forms from your employer or insurance company. Alternatively, you can download the forms, " Patient Short Term Disability Form" or "FMLA Form."
- Complete all parts of the form that are to be completed by the employee.
-
Mail or drop off the form(s) at our office.
Include a check payable to Adult Primary Care Associates ($25
for each form submitted.) Our address is 575 Professional Dr.
Suite 510, Lawrenceville, GA 30046
- Please allow 10 business days for completion.
- Please remember, the forms will be completed after we receive your payment. We encourage you to submit the forms as soon as possible.
The fee schedule for some common forms is:
- Family Medical Leave Act $25
- One Page Disability form $25
- Multiple Page Disability form $50
- Functional Capacity Evaluation $50 to $150
- Narrative Summary $150 1st hour
Medical Records:
In accordance with the Georgia General Assembly Unannotated Code 31-33-3, the medical records fee is as follows:
- $25.88 for administrative charges associated with the search,
retrieval of medical records
- $9.70 for each record requiring certification
- The actual charge for postage incurred in record's mailing
- $0.97 per page for the first 20 pages of the patient's record
copied
- $0.83 per page for pages 21-100
- $0.66 for each page copied in excess of 100 pages
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