FMLA & Administrative Forms Policy

Types Of Forms We May Complete

• Family and Medical Leave Act (FMLA) forms, including employer-provided forms and the federal WH-380 series
• Short-term disability forms
• Long-term disability forms (completed on a limited basis; see below)
• Family-member FMLA certification forms (see below for requirements)
• Work or school excuse letters
• Other medical necessity letters, as clinically appropriate

Please note: We do not complete total and permanent disability determinations. If you are seeking permanent disability adjudication, you will need to work with a specialist or undergo a formal functional capacity evaluation (FCE) through an appropriate referral.

Eligibility Requirement — FMLA And Short-Term Disability Forms Only

To request completion of an FMLA or short-term disability form, you must be an established patient of Lenox Medical Clinic with a minimum of three (3) documented office visits within the past six (6) months for the same condition described in the form.

We cannot complete FMLA or short-term disability forms based on limited clinical history or for conditions that have not been actively evaluated and managed at this practice. Forms submitted without the required visit history will be returned to you without completion.

This is a firm policy with no exceptions.

This eligibility requirement does not apply to work or school excuse letters or other simple medical documentation.

How To Submit A Request

1. Obtain the form from your employer, insurance company, or requesting organization.
2. Complete the patient section of the form before submitting it to us.
3. Bring the completed form to our office in person. We do not accept submissions by fax, mail, or through the patient portal.
4. Pay the applicable fee in full at the time of submission. Fees are non-refundable.
5. A mandatory consultation visit with your provider is required before FMLA or short-term disability forms will be completed. This visit is billed separately as a self-pay consultation and is not included in the form fee.

Fee Schedule

• All fees are self-pay and are NOT covered by insurance.
• Fees are due in full at the time of form submission.
• Fees are non-refundable, regardless of whether the form can ultimately be completed.

Processing Time

Please allow up to 10 business days after your mandatory consultation visit for your form to be completed.

The 10-business-day period begins only after all of the following have occurred:

• The mandatory consultation visit has been completed
• The form has been submitted in person with all patient sections fully completed
• All required supporting documentation has been received
• The applicable fee has been paid in full

We cannot guarantee completion by any specific date and do not offer expedited or rush processing. We strongly encourage you to submit your request well in advance of any employer or insurance deadline. Lenox Medical Clinic is not responsible for missed deadlines resulting from late submission.

Long-Term Disability Forms

Long-term disability forms are completed on a limited basis at this practice. If you need long-term disability documentation, please discuss your specific situation with your provider at your consultation visit to determine whether we are able to assist with your particular form.

Family-Member FMLA Certification Requests

Lenox Medical Clinic may complete FMLA certification forms for patients who are seeking leave to care for a family member, provided that sufficient supporting documentation is available.

To request a family-member FMLA certification, you must provide:

• The completed employer FMLA form with all patient sections filled out
• Supporting records or a treating physician's note from the provider caring for the family member

Family-member FMLA certification forms are subject to the same $150.00 fee, mandatory consultation visit requirement, in-person submission requirement, and 10-business-day processing time as standard FMLA forms. If the documentation provided is insufficient to support the request, the clinic may decline to complete the form.

Functional Capacity And Physical Capacity Evaluations

Lenox Medical Clinic does not perform Functional Capacity Evaluations (FCE) or Physical Capacity Evaluations (PCE). If a form you are submitting requires an FCE, PCE, or similar formal capacity evaluation as part of the certification, you will need to be referred to a specialist or another qualified evaluator. Our staff can discuss referral options with you at your consultation visit.

No Guarantee Of Approval

Completion of a form by Lenox Medical Clinic documents the clinical information supported by your medical record. It does not guarantee:

• Approval of leave, disability benefits, or other benefits by your employer
• Approval of a claim by your insurance company or disability plan
• Any specific outcome with the requesting organization

Final decisions regarding leave, benefits, or claims are made solely by the employer, insurer, or requesting agency.

Right To Decline

Lenox Medical Clinic reserves the right to decline completion of any administrative form if:

• The patient does not meet the eligibility requirements described in this policy
• The patient's medical record does not contain sufficient clinical documentation to support the request
• Required documentation or supporting records have not been provided
• The form requests information, certifications, or evaluations outside the scope of this practice
• The provider determines, in their clinical judgment, that completion of the form is not appropriate