Instructions for Submitting Your Form

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Instructions

• This site is for City of Hope - Duarte patients or their caregivers who need a Disability, FMLA, or other Form completed to apply for disability benefits, employer leave, or other medical need.
• If you are a Kaiser Permanente patient being treated at City of Hope - Duarte, you will need to submit your Form(s) to your Kaiser Physician at: https://healthy.kaiserpermanente.org/southern-california/support/medical-requests
• 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 7–10 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.
• Note: Your Form(s) will be submitted to your care team after your surgery is completed. Please allow up to 10 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, Electronic EDD, or FMLA Forms.
  • $30 standard processing for any other Form type.
  • $15 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 Medi-Cal coverage. Coverage will be verified before completing your Form.
• If you are submitting a claim or appeal to one of the Public Benefit Programs listed below OR if you are currently receiving assistance from one of these programs, please select "Public Benefit Program" on the next screen as your Health Insurance Type:
  • The In-Home Supportive Services Program
  • The California Work Opportunity and Responsibility to Kids (CalWORKs) Program
  • Social Security Disability Insurance benefits
  • Supplemental Security Income/State Supplementary Payment Program (SSI/SSP) for the Aged
  • Blind and Disabled SSI/SSP benefits
  • Federal veterans service-connected compensation and non-service connected pension disability benefits
  • Discharge of a federal student loan based on total and permanent disability
  • CalFresh
  • The Cash Assistance Program for Aged, Blind, and Disabled Legal Immigrants
  • Government-funded housing subsidy or tenant-based housing assistance Program
• 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 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, 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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