Short Term Disability/FMLA ROI Form
ONLY complete and return this form if you require STD/FMLA paperwork to be completed for your employer.
We are pleased to assist you in completing your Disability and FMLA forms. Be advised there will be a 7-10 business day processing time frame, as
well as a processing fee based on the type of form requiring completion.
We understand you may have an urgent deadline for your paperwork and will do our best to accommodate; however all paperwork will be
processed in the order that we receive it without exception. I understand that the processing timeframe does not begin until all required pieces of
documentation have been received by Iowa Ortho, this includes a signed release of information, the forms requiring completion and payment in
full.
If you wish to retain a copy of the form for your records, you may do so by requesting a copy from our medical records department.
By law, we are required to have you provide us with a signed authorization giving your permission to disclose your information.
If you prefer to print and complete the form by hand, please download a pdf version of the form by clicking here.
Guide to Short Term Disability/Family Medical Leave Act Paperwork:
If you are having surgery and will be unable to work, your employer may require you to have paperwork completed. The company that processes your forms may have a deadline for submission, please remember our processing time is 7-10 business days, beginning the 1st day all required information is received by our office. The required pieces of information are listed below.
Getting Started: Iowa Ortho will require 3 key pieces of information in order to process your STD/FMLA form completion request. The 10 day processing time for forms will not begin until ALL required pieces have been received.
- A signed Release of information:
- This ONLY needs to be filled out if you have paperwork that needs completed for an employer or short term disability company. This tells us who you are giving us legal permission to release your medical information to. This is required regardless of who will be receiving the information ie: insurance company, employer, yourself. Electronic signatures are not accepted and the release is only valid for 1 year. If you have more than 1 set of forms to be completed, please provide both companies as they must be listed on the release with fax/address provided in order for us to legally send the completed documents.
- Documents/Forms needing completed by the physician:
- Your employer should provide these to you, be sure if there is a patient portion to be completed this is done prior to sending to Iowa Ortho.
- Payment in full:
- $20 charge PER set of forms. For example: if you have Short Term Disability and Family Medical Leave Act forms to be completed this would be $20 per set, totaling $40.
What you can expect from us: Once you have submitted the 3 required pieces of information, your paperwork will be completed and sent to the employer or insurance company information you have provided on the signed release of information with 10 business days. The 1st business day begins the day all 3 required pieces of information have been received.
NOTE: Not all forms are appropriate for our physicians to complete. Non STD/FMLA form requests will be reviewed on a case by case basis to deem appropriate for our office to complete. This includes: Long term disability and child support forms, mental status to care for children forms, DHS, etc.
The Release of information can be filled out by a 3rd party, spouse or family member but the patient must be the party to sign the release. The only exception is Medical Power of Attorney, child and/or dependent adult, who must have the forms completed by a parent or legal guardian.
Completed forms can be emailed directly to medrec@iowaortho.com to initiate the process.
If you have questions on the status on your forms, payment, or release of information please call 515-247-8400 to speak with a representative that would be happy to assist you.
I authorize Iowa Orthopedic Center to provide charts, notes, x-rays, operative reports, lab and medication records and all other medical
information about me, including medical history, diagnosis, testing, test results, prognosis and treatment of any physical or mental condition,
including: any disorder of the immune system, including HIV, AIDS or other related syndromes or complexes; any communicable disease or
disorder; any psychiatric or psychological condition, including test results; any condition, treatment, or therapy related to substance abuse,
including alcohol and drugs; and any non-medical information requested about me, including things such as education, employment history,
earnings or finances, return to work accommodation discussions or evaluations and eligibility for other benefits or leave periods including but not
limited to claims status, benefit amount, payments, settlement terms, effective and termination dates, plan or program contributions.