We receive many requests for completion of forms. This requires extra work, time and financial resources in excess of what is normally needed to complete the medical record. The fee must be paid when you drop off the form(s), or if they are being faxed or mailed to our office, please pre-pay before they are completed.
Please submit your request for completion of forms well in advance of when they are needed. We will attempt to complete the forms as quickly as possible however, in order to properly address them we need adequate time to review your records.
We require payment for the completion of the following forms that you ask us to complete on your behalf:
| Type of Form | Charge |
|---|---|
| STD – Short Term Disability (employer provided) | $10.00 |
| STD – Short Term Disability (supplemental policy) | $10.00 |
| LTD – Long Term Disability (employer provided) | $10.00 |
| LTD – Long Term Disability (supplemental policy) | $10.00 |
| FMLA – Family Medical Leave Act (standard form) | $10.00 |
| FMLA – Family Medical Leave Act (non-standard form) | $10.00 |
| Attending Physician Statement | $10.00 |
| Auto Insurance Attending Physician | $10.00 |
| PA Game Commission | $10.00 |
| Federal Family Education Loan Discharge | $10.00 |
| Bank/Credit Card Payment Deferral | $10.00 |
| Medicare Patient (works part-time) | $10.00 |
| Life Insurance Application | $25.00 |
| ADA – Americans with Disabilities Act | $30.00 |
| Fitness for Duty | No Charge |
| School Medical Excuse | No Charge |
| Crime Victims | No Charge |
| Parking Placard Application | No Charge |
| County Assistance Employability | No Charge |
| County Assistance Health/Medication | No Charge |
| Nursing Home Update/Order | No Charge |