Forms- An administrative fee is charged for the completion of certain work-related documents presented by patients. These documents include disability insurance benefit forms, Family and Medical Leave Act (FMLA) forms and return-to-work forms. Typically, your employer or insurance company requires these forms when a medical condition prevents you from reporting to work. A licensed medical professional must sign these documents verifying that the information is correct. You may either obtain the forms from your employer or download the attached forms. **Note, complete all parts of the form that are to be completed by the employee. Mail or drop off the forms at our office including a check payable to Kenneth J. Sobel, MD. Allow 10 business days for processing after payment is processed.

Fee Schedule:

• Family Medical Leave Act $25
• One Page Disability form $25
• Multiple page Disability form $50
• Functional Capacity Evaluation $50 to $150
• Narrative Summary $150 1 st hour
• Medical Records $60 (or pro-rate fee)
• Returned Check Charge $30

A. New Patient Forms

1. Registration Information
2. Medical History
3. Patient Release Form
4. Records Transfer Request

B. Medical Records Request

C. Medication Prior Authorization

D. Disability Forms

1. Short Term (generic form)

E. Patient Survey (fax completed survey to 770-513-7986)