Instructions for Submitting Your Form

---

Instructions

• This site is for City of Hope 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, 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.
• You may choose to have your Form processed within 5-7 business days (standard) or within 1-3 business days (expedited).
• Note: Your Form(s) will be submitted to your care team after your surgery is completed. Please allow up to 7 business days following your surgery for your care team to process and finalize the Form(s).
  If you need a work excuse note before your surgery, you may request one directly from your care team.
• Form processing fees are as follows:
  • $40 standard processing for Disability or FMLA Forms.
  • $30 standard processing for any other Form type.
  • $15 standard processing for a continuation or update to a current Form.
  • Expedited turn-around is an additional $20 per Form.
• Pre-payment is required before your Form can be processed.
• The processing time begins once we have received all necessary items: prepayment, 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 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 credit/debit card to make payment.
  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.

---