Instructions for Submitting Your Form

---

Instructions

• This site is for patients or their caregivers who need a form completed to apply for disability benefits, employer leave, or various other patient assistance.
• ONLY ONE FORM is permitted per request. For EACH type of form you need completed by the clinic, you MUST upload one form only, pay for it, 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 - then 3 separate independent online submissions.
• IF YOU UPLOAD MORE THAN ONE FORM PER ONLINE SUBMISSION THEN YOUR FORM SUBMISSION WILL BE REJECTED.
• You may choose either the standard form processing time (within 7 business days) or expedited form processing time (within 3 business days).
• The processing time begins once we have received a completed request/authorization and the respective 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 or 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 picture or PDF of your form ready to be uploaded
  3. (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.

---