Instructions for Submitting Your Form

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Instructions

• This site is for Ally Psychiatry patients or their caregivers who need a Disability, FMLA, or other Form completed to apply for disability benefits, employer leave, or other medical need.
• ONLY ONE FORM is permitted per request. For EACH type of Form you need completed, you MUST upload one Form only, provide payment if applicable, and submit it online. If you have more than one Form to be processed then you will need to submit and pay for each Form separately. Three Forms = 3 separate independent online submissions.
• IF YOU UPLOAD MORE THAN ONE FORM PER ONLINE SUBMISSION THEN YOUR FORM SUBMISSION WILL BE REJECTED.
• Completion of new and updated Forms can be requested on this site.
• Please note that our standard processing time is approximately 5-7 business days from the date all required information is received. This timeframe is an estimate and may vary depending on Form complexity and Provider availability.
• Form processing fees are as follows:
  • $80 standard processing for Disability or FMLA Forms.
  • $35 standard processing for any Other Form type.
  • $20 standard processing for a continuation or update to a current Form.
• Pre-payment is required before your Form can be processed. Note there are no Form fees for Workers' Compensation or patients with Medicaid coverage. Coverage will be verified before completing your Form.
• The processing time begins once we have received all necessary items: prepayment if applicable, a completed request/authorization, and the Form.
• Once completed, your Form will be made available online for you to save, print, or email as needed. You may also ask for your Form to be delivered to a third party (such as an insurance company, employer, or any party of your choice).
• You will need the following:
  1. A valid driver's license or other valid state-issued ID.
  2. A credit/debit card to make payment, if applicable.
  3. A picture or PDF of your Form ready to be uploaded.
  4. Any additional documentation you may have to support your claim, i.e. Paid Family Leave Bonding Attachments, Paid Family Leave Care Attachments, or Paid Family Leave Military Assist Attachments.
  5. (Optional) The contact information of the recipient, if you want your completed Form sent to a third party (e.g. an employer or insurance company).

Please have these items handy before you start!

To keep you up-to-date, you will receive two text alerts - one to confirm that your request is in process and one to let you know that your request is complete.

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