Forms To Be Completed By Physician

  • Family Medical Leave Act (FMLA), Short Term, and Long Term Disability Forms:
  • Prior to FMLA, Short Term, or Long Term Disability forms being filled out by your physician, please download and print each of the following forms. (to be completed by the patient).THESE FORMS ARE TO BE COMPLETED BY THE PATIENT IN THEIR ENTIRETY.  PLEASE READ AND UNDERSTAND EACH.

     

    PLEASE NOTE:

    • The QUESTIONNAIRE, FORMS POLICY, as well as the patient portion of YOUR
      FORM must be filled out prior to scheduling your consultation.
    • Any forms we receive without these items completed (or incomplete sections to be filled out by you the patient) will be mailed back to you at your expense.

     

  • The cost of this appointment is $85.00. It is not billable to your insurance carrier and must be paid in advance / prior to your appointment.
  • Disability Access Parking Privileges Form: Should your physician feel that this form can be completed without examination, please complete all sections other than the physicians section and mail or bring the completed form to our office. There will be a charge of $25.00 for this service that is due and payable prior to form completion. (Enclose payment if mailing)
  • Sports Forms / Exam:
    This form will be completed during the course of an exam. An appointment may be made by calling 256-383-4447. This exam is typically not covered by insurance, so be prepared to pay $75.00 prior to exam.