Time Away From Work Service Center

PO Box 14674
Lexington, KY 40512-4674

February 19, 2020 Phone: (855) 858-7557

Fax: (888) 999-7573
Patricia J. Khan
430 E Drury Ave
Kissimmee, FL 34744

Sedgwick Claims Management Services, Inc.

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 Time Away From Work: Instructions for Employees
Medical records relevant to your absence are necessary for a determination of eligibility for disability benefits or applicable
leaves of absence. It is your responsibility to make sure you return the appropriate documentation:
1. The enclosed Attending Physician Statement form should be forwarded to your treating physician immediately in order
for eligibility to be determined for Short-Term Disability benefits.
 If you are only applying for FMLA or another leave, please contact the Time Away From Work Service Center at
855-858-7557 for the appropriate form.
 Any charges for the requested medical documentation are your responsibility.
2. We have provided the Authorization for Release and Use of Medical Information (ROI) form to assist you in allowing the
Time Away From Work Service Center to obtain medical information on your behalf. Completion of this form is not
mandatory, but without the completion of the ROI, the Time Away From Work Service Center may be limited in its ability
to assist you with obtaining information for your claim. If you choose to complete the ROI you should:
 Fax the signed ROI form to the Time Away From Work Service Center
 Provide a signed copy to your treating physician along with the Attending Physician Statement.
All medical documentation relevant to your leave must be received by the Time Away From Work Service Center by the
designated due date - 03/22/2020. Short-Term Disability benefits will not be paid if medical documentation is not received or
does not support disability.
While on leave, you need to continue to follow local practices in contacting your Supervisor on a regular basis.
Your facility or applicable collective bargaining agreement may have rules about PTO use while on a leave of absence.
If your disability is of extended duration, periodic requests will be made for updated medical records. Failure at any time to
provide the requested relevant records may prevent you from receiving benefits during your leave and disability.
The Return to Work release form must be returned to the Time Away From Work Service Center at least three days prior to your
anticipated return to work. If you are not out eight days or more the Return to Work release may not be required.
Short-Term Disability payments will be processed based on your normal pay schedule and payment method.
Any Short-Term Disability payments received may be taxable income.
 You have the option of completing the W-4S form enclosed to allow a designated fixed amount of federal taxes to
be deducted from your disability benefits in addition to Medicare and Social Security taxes.
 You will receive a separate W-2 form from Sedgwick at the beginning of next year for any disability payments you
received this year.
Outside employment while on an approved leave of absence is cause for termination, unless such employment is specifically
approved in writing prior to leave being taken. This applies to all forms of employment, including employment entered into
prior to the leave.
You will receive a monthly invoice for your health and group benefits from BConnected throughout your time away from work.
 The invoice for the previous month’s benefits will be mailed to your home address the second week of the
following month.
 Deductions for 401k or 401k loan repayments are not eligible for direct bill. Please contact BConnected for more
information about 401k or 401k loan repayments.
You may want to contact BConnected if your leave is the result of a Qualifying Family Event, such as a dependent’s birth,
death, adoption or placement with you for adoption. You have 31 days to call BConnected at 800-566-4114 to add/remove a
dependent or change benefit elections.
You are required to report any time away from work to your supervisor within two hours of the start of your shift and to the
Time Away From Work Service Center within 24 hours of the start of your shift.
The determination of your claim for disability benefits will be made by the Time Away From Work Service Center.
Contact Information for the Time Away From Work Service Center:
Mail: Time Away From Work Service Center; P.O. Box 14674; Lexington, KY 40512-4674
Telephone: 855-858-7557
Fax: 888-999-7573

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!C00937933.222-6065!
 Helpful Resources
The HCA Hope Fund
At HCA Healthcare, our top priority is taking excellent care of our
patients. But, we also take care of each other. The HCA Hope Fund is
an employee-funded non-profit that has helped more than 23,000
HCA-affiliated employees and their immediate families in times of
hardship, including disaster, extended illness or injury, domestic violence, death of a loved one and other
situations. To qualify, the applicant needs to be a full-time, part-time, or PRN (working at least 12 hours a
week) employee at an HCA-affiliated facility. The grant maximums are based on the situation, in times of
disaster, grant amounts based on the family size and level of damage. To apply for assistance from the Hope
Fund, fill out an application online at www.hcahopefund.com. If you have questions, call
(877) 857-4673 or send an email to hopefund@hcahealthcare.com.

Employee Assistance Program

All HCA-affiliated employees and their families have access to a FREE Employee Assistance Program (EAP),
a confidential counseling and referral service providing personal, legal and financial services. These services
can help you deal with a wide variety of life’s challenges that could affect your health, relationships, financial
situation and/or job effectiveness. Whether the issue is large or small, you can contact the EAP for assistance
24 hours a day, 365 days a year. Call the EAP to talk one-on-one with an experienced, licensed counselor for
support with:

 Coping with the diagnosis of an illness or with a chronic illness

 Depression
 Stress management
 Relationship difficulties
 Work/life balance
 Managing time away from work
 Dealing with emotions
 Return-to-work concerns
 Working with others
 Financial planning
 Substance abuse treatment and recovery
 Building resilience after a disability

EAP counselors can help you assess your concerns, think through your options, develop a plan, identify
resources for additional help and provide referrals to professional service providers when appropriate

To access more details and online resources, go to HCAhrAnswers.com*, click HCA Rewards and enter EAP
in the search box.
To speak to a counselor at any time, call (800) 434-5100. (Employees in North Texas Division, please call 888-
600-4327.)
*If your facility does not use HCAhrAnswers, log in to HCArewards.com and enter EAP in the search box.
Time Away From Work Service Center
PO BOX 14674
Lexington, KY 40512-4674

February 19, 2020

Phone: (855) 858-7557
Fax: (888) 999-7573
Patricia J. Khan
430 E Drury Ave
Kissimmee, FL 34744

Re: Time Away From Work Service Center Short-Term Disability (STD) and Leave of Absence
Claim Number: 30204551727-0001

Dear Patricia J. Khan :

The Time Away From Work Service Center is the Short-Term Disability and Leave Administrator for your employer.
Thank you for contacting us about your request. We are here to assist you during your time away from work. Please
read the following information and contact me if you have any questions.

The Time Away From Work Service Center has been notified of your absence from work due to disability. When we
receive medical documentation from your physician, your claim will be processed. The medical documentation to
support your claim is due on or before 03/22/2020.

Actions required:

1. Return completed Attending Physician Statement by 03/22/2020. This form is not mandatory for
consideration of FMLA leave but is required for consideration of paid Short-Term Disability benefits.

2. Return completed Medical Authorization for Release of Information (ROI) form as soon as possible. This
form is not mandatory for consideration of FMLA leave or paid Short-Term Disability benefits.

Attending Physician Statement

The attached Attending Physician Statement will be used to evaluate your absence for Short-Term Disability. Please
have the Attending Physician Statement completed and returned no later than 03/22/2020. In addition, if and when
we receive a completed ROI form, we will attempt to gather this information from your physician by phone.

If you do not submit the Attending Physician Statement within the above time frame, your request for leave may be
denied or its commencement delayed until the Attending Physician Statement or other medical documentation is
submitted. Failure to submit the form may result in you not being paid benefits. You will be required to furnish
periodic reports of your status and intent to return to work upon request. Generally, those reports will not be
required more frequently than every 30 days. If the circumstances of your leave change and you are able to return
to work earlier than the date you indicated, you will be required to notify your supervisor and the Time Away From
Work Service Center at least three workdays prior to the date you intend to report for work.

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Medical information you have shared is considered confidential under the Family and Medical Leave Act
(FMLA) and the Americans with Disabilities Act (ADA). This information is only shared when necessary on a
need-to-know basis with your employer, the Time Away From Work Service Center, or outside medical
professionals retained to review your leave request in an effort to assist in your return to work and to verify
your eligibility for leave. Return to Work information (e.g., restrictions) will be shared with your supervisor or
Human Resources department as necessary on a need-to-know basis.

Your benefit amount may be offset by other sources of income payable during your period of disability such as state
disability plan benefits. If you are receiving other income, you must furnish the Time Away From Work Service Center
with proof of the amount in the form of an award letter, pay stub or other documentation. Please contact me if you
have any questions regarding the evidence you should submit.

Medical Authorization for Release of Information

We have enclosed a Medical Authorization for Release of Information (ROI) form that can allow us to obtain
information from your physician to complete your Short-Term Disability claim. Please note that completion of this
form is not mandatory. If you elect not to complete this form, the Time Away From Work Service Center will rely on
submitted medical documentation to determine if you qualify for Short-Term Disability. If you choose to sign the
Medical Authorization for Release of Information form, please provide a copy to your treating physician. If you have
more than one physician, please give a copy to each.

Family and Medical Leave Act (FMLA) Eligibility

Basic Eligibility Criteria for FMLA:

 12-month length of service requirement (at the time your leave begins)
 1,250 hours worked during the 12-month period immediately preceding your leave

We have reviewed the request for leave under the Federal Family and Medical Leave Act (FMLA). We are pleased to
inform you that you meet the FMLA's basic eligibility requirements. Now we need to gather supporting information
to determine whether this case for FMLA protected time off can be approved.

It is important to note, if you have requested a first day of absence in the future, eligibility will be determined by the
Time Away From Work Service Center as of that date. If the number of hours worked in the 12 months preceding
your first day of leave is different than the number of hours verified as of the date of this letter, you may not be
eligible for FMLA leave and an amended notice of eligibility and Rights & Responsibilities will be sent to you.

FMLA Rights & Responsibilities:

If the eligibility notice above indicates that you meet the eligibility requirements for taking FMLA leave, you may still
have FMLA leave available in the applicable 12-month period. In order for us to determine whether your absence
qualifies as FMLA leave, you must return to us sufficient certification to support your request for FMLA leave no later
than 20 days from the date of this notification, or 03/22/2020. If sufficient information is not provided in a timely
manner, your leave may be denied. If you would like to apply for FMLA only, please contact the Time Away From
Work Service Center so we may provide you with the appropriate form.

If your leave does qualify as FMLA leave, you will have the following responsibilities while on FMLA leave:

 During your leave, your employer will continue to pay its portion of your group health and group
benefit premiums and you must pay your share, if any, of the premiums. During your leave, your

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 share of the premiums will be direct billed to you at your home. Please contact BConnected at (800)
566-4114 for more information regarding payments for benefit continuation during your leave. To
speak to a an operator, simply say “speak to operator”.

 While on leave you will be required to furnish periodic updates of your status and intent to return to
work upon request to the Time Away From Work Service Center and your supervisor.

If your leave does qualify as FMLA leave you will have the following rights while on FMLA leave:

 You have the right under the FMLA for up to 12 weeks of unpaid leave in a 12-month period calculated using
a “rolling” 12-month period, measured backward from the date of any FMLA leave usage.
 Your health and group benefits must be maintained during any period of unpaid leave under the same terms
and conditions as if you continued to work.
 You must be reinstated to the same or an equivalent job with the same pay, benefits and terms and
conditions of employment on your return from FMLA-protected leave. If your leave extends beyond the end
of your FMLA entitlement, you do not have job protected leave under FMLA.
 If we have not informed you above that you must use accrued paid leave while taking your unpaid FMLA
leave entitlement, you have the right to have sick, vacation, and/or other leave run concurrently with your
unpaid leave entitlement, provided you meet any applicable requirements of the leave policy. Applicable
conditions related to substitution of paid leave are referenced or set forth below. If you do not meet the
requirements for taking paid leave, you remain entitled to take unpaid FMLA leave.
 If you do not return to work following FMLA leave for a reason other than: 1) the continuation, recurrence,
or onset of a Serious Health Condition which would entitle you to FMLA leave; 2) the continuation,
recurrence, or onset of a Serious Health Condition of a covered Servicemember‘s serious injury or illness
which would entitle you to FMLA leave; or 3) other circumstances beyond your control, you may be required
to reimburse your health and group premiums paid on your behalf during your FMLA leave.

Once we obtain the information from you as specified above, we will inform you, within five business days,
whether your leave will be designated as FMLA leave and count towards your FMLA leave entitlement.

Basic Eligibility Criteria for General Medical Leave of Absence (GML):Employment status must be full or part-time
and PRN employees are not eligible.
We are pleased to inform you that are eligible for General Medical Leave of Absence.

Americans with Disability Act Amendments Act (ADAAA)

If your leave request is for your own Serious Health Condition and you would like to discuss an accommodation in
addition to this request for leave, please contact your facility’s Human Resources department as soon as possible.

FLORIDA RESIDENTS – Any person who knowingly and with intent to injure, defraud, or deceive any insurer
files a statement of claim or an application containing any false, incomplete, or misleading information is
guilty of a felony of the third degree.

Information regarding your claim status, date medical information was last received, anticipated return to work
date, and payment information, if applicable, can also be obtained 24 hours a day, 7 days a week through our
Interactive Voice Response (IVR) system at 855-858-7557, or login to www.HCArewards.com, click on the Time Away
From Work Program icon and the “Submit/View Claims” button. When mySedgwick opens, click on the “View” tab
and enter your identifying information to search for your claim. You can also upload your documents to your claim
from your mobile device or your computer by selecting the “Upload a File” link in the “Related Links” window and
choosing the files or images you would like to submit.

For additional information please find a link to a short video: https://play.vidyard.com/JK6p5x2x3uasYW6KNHF5Pk

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We understand that during your leave you may have questions and need assistance. We are here for you.
Please feel free to call me at the Time Away From Work Service Center at 855-858-7557, Monday through
Friday 6:00 a.m. – 7:00 p.m. (CST). We hope you are feeling better soon.

Kindest regards,

Angela W.
Disability Advocate
Phone: 855-858-7557
Fax: 888-999-7573

SPANISH (Español): Para obtener asistencia en Español, llame al [(855) 858-7557].

TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa [(855) 858-7557].
CHINESE (中文): 如果需要中文的帮助，请拨打这个号码 [(855) 858-7557].
NAVAJO (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' [(855) 858-7557].

Enclosures: Authorization for Release and use of Medical Information

Attending Physician Statement
Return to Work Release Form
W-4

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 AUTHORIZATION FOR RELEASE AND USE OF MEDICAL INFORMATION

I authorize each of the parties identified below to use and disclose any and all of my individually identifiable medical or health
information, as described below, for purposes of administering my claim or request for reasonable accommodation. I
understand that the information about me that I authorize to be used or disclosed may be re-disclosed in accordance with the
terms of this Authorization by the recipient thereof and may no longer be protected by federal or state privacy laws or
regulations.

I specifically authorize physicians, nurses and hospitals to communicate my individually identifiable medical or health
information by any means, including written or telephonic communications or by direct interview, whether or not I am present
during, or notified of, such communications, and I hereby authorize Sedgwick to initiate and conduct such communications
whether or not I am present or have received notice thereof.

1. What Information is covered by this Authorization? This authorization applies to all medical and non-medical information
that is needed by Time Away From Work Service Center, its parent, subsidiaries and affiliates, its administrators including
Sedgwick, and its insurers, related to any of the following: request for reasonable accommodation; workers’ compensation
claim; claim for disability benefits; claim for FMLA; or claim for leave. My information to be disclosed may include, but is
not limited to, medical or health history, chart notes, prescriptions, diagnostic test results, x-ray reports, records received
from other health care providers, information regarding pre-existing health or medical conditions or illnesses, as well as
my occupation and employment activities, employee/employment records, earnings or finances, applications for insurance
coverage, prior claim files and claim history.

If directly related to my claimed condition or illness, this information may include the following,
Please check yes or no and initial:
HIV test results, HIV or AIDS information. YES NO Initial here
Psychiatric information. YES NO Initial here
Information related to drug or alcohol abuse. YES NO Initial here

2. Who may disclose and receive Information under this Authorization?

A. Any person or facility that attends, treats or examines me, any financial institution, accountant, tax preparer,
insurance company, consumer reporting agency, insurance support organization, employers, government agencies
including the Social Security Administration, or any other person or organization that possesses any of the
information described above, is to make this information available to Time Away From Work Service Center, its
parent, subsidiaries and affiliates, insurers or administrators, including Sedgwick; and or any of its agents,
representatives or independent contractors.
B. When relevant to my claim, Sedgwick to re-disclose (without my further authorization) any and all of my individually
identifiable medical or health information (whether obtained pursuant to this authorization or otherwise from any
person or entity) to any of the following, (a) Any person or facility that attends, treats or examines me; (b) Any person
or facility that impacts determination of my claim or that coordinates my benefits; (c) My employer and its affiliates
and their representatives, independent contractors and service providers that may receive any such information from
my employer to the extent permitted by state or federal law; (d) service providers for my long term disability claim or
workers’ compensation claim or (e) The Social Security Administration or a social security or vocational rehabilitation
vendor. Sedgwick may use my information obtained pursuant to this authorization in any other claim matter that
Sedgwick may administer or handle related to me.
3. How long this Authorization is Valid? This authorization is valid during the duration of my claim(s) and any future related
claims, unless a different period is required under applicable federal or state law.

4. Revocation of this Authorization. Unless otherwise provided by federal or state law, I understand that I may revoke this
authorization at any time by notifying, in writing, Sedgwick at, PO Box 14674; Lexington, KY 40512-4674; Fax: 888-999-
7573 of my revocation and that my revocation shall be effective upon Sedgwick’s receipt of my notice of revocation. I also
understand that my revocation of this Authorization will not have any effect on any actions taken by Sedgwick before it
receives my revocation.

5. Processing of Claims. I understand that this Authorization is generally necessary for the processing of my claim or request
for reasonable accommodation. Failure to sign this Authorization may impair or impede the processing of my claim or
request for reasonable accommodation.

6. Refusal To Sign. I further understand my health care providers will not condition my treatment, payment, enrollment or
eligibility on my refusal to sign this Authorization.

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I understand that I have the right to request and receive a copy of this authorization. I understand that I have the right to
inspect the disclosed information at any time. A photocopy of this authorization shall be valid and is to be accepted with the
same effect as the original.

“The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II
from requesting or requiring genetic information of an individual or family member of the individual, except as specifically
allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to
this request for medical information. ‘Genetic information,’ as defined by GINA, includes an individual’s family medical history,
the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member
sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member
or an embryo lawfully held by an individual or family member receiving assistive reproductive services.”

Printed Name of Patient or Patient’s Representative Representative’s Relationship to Patient, if

applicable
30204551727-0001

Claim Number Last 4 Digits of Patient’s SSN Patient’s Date of Birth

Signature of Patient or Patient’s Representative Date Signed

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Return to Work Release Form
This Return to Work Release Form must be completed by your Health Care Provider no more than 30 days
prior to your anticipated return to work date, and submitted to the Time Away From Work Service Center
at least three days prior to your return to work. Please also follow any Return to Work processes required
by your facility.

For additional information please find a link to a short video: https://play.vidyard.com/Hu6FxB9wfCatDtn7Wt85L2

This section is to be completed by the EMPLOYEE

Employee Name: Patricia J. Khan Employee ID: 040308214
Claim Number: 30204551727-0001 Date leave began:
HRCO: 5726 Process Level: 01323
I understand that I cannot return to work without a release from my health care provider.
Employee’s Signature: Date:

This section is to be completed by the HEALTH CARE PROVIDER

I have examined the employee named above and certify that this person is medically able to resume
working on: _____ / _____ / _____
With No Restrictions
This employee can return work:
With Restrictions (outline details below)
If the employee is returning with restrictions, please state in detail the employee’s restrictions and the
duration of the restriction:

Period of restrictions _____ / _____ / _____ to _____ / _____ / _____

Signature of Health Care Provider: Date:

Name of Health Care Provider (Please Print):

Address of Health Care Provider:

Phone Number of Health Care Provider:

The completed form can be faxed or mailed to the Time Away From Work Service Center at:
PO Box 14674
Lexington, KY 40512-4674
Claim services administered on behalf of Prudential Insurance Company of America

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 Fax: (888) 999-7573

Claim services administered on behalf of Prudential Insurance Company of America

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.
Employee Name: Patricia J. Khan
Claim Number: 30204551727-0001
Medical Records/Form Due Date: 03/22/2020
CONCURRENT DISABILITY AND LEAVE
STATEMENT OF INCAPACITY/ATTENDING PHYSICIAN STATEMENT
To Be Completed by Physician (Please Type or Print)
Time Away From Work Service Center
P.O. Box 14674, Lexington, KY 40512-4674
Telephone: (855) 858-7557 Facsimile: (888) 999-7573
Patient’s name: Patricia J. Khan Date of Birth: 05/19/1954

SECTION 1: REQUIRED INFORMATION TO SUPPORT FMLA/STATE LEAVE

1. Will the patient be incapacitated for a single continuous period of time due to his/her medical condition, including any
time for treatment and recovery? Yes  No 
If “Yes”, provide the beginning and ending dates for the period of incapacity: _____/_____/____- _____/_____/____
2. Has the patient recovered sufficiently to return to work? Yes  No 
If “Yes”, give the date the patient was able to return to work _____/_____/____
If “No”, in your opinion when, may work be resumed? (Please do not use “indefinite”, “unknown”, “undetermined”, etc.)
If a date cannot be determined, please estimate in days, weeks or months. _____/_____/_____

3. Has the patient recovered sufficiently to return to restricted work? Yes  No 

If “Yes”, indicate date restrictions begin: _____/_____/_____ Date restrictions end: _____/_____/_____
Restriction (s) required:
________________________________________________________________________
______________________________________________________________________________________________
4. Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
Yes  No  If “Yes”, give dates of admission:____________________________________________________
5. Date(s) you treated the patient for condition:___________________________________________________________
6. When is the patient’s next office visit? _____/_____/____
7. Was medication, other than over-the-counter medication prescribed? Yes  No 
8. Is the medical condition pregnancy? Yes  No  If “Yes”, expected delivery
date:________________________________
9. Is the patient unable to perform any of his/her job functions due to their condition: Yes  No 
If “Yes”, identify the job functions the employee is unable to perform (use the list of the employee’s essential functions
or job description, if included, or answer this question based upon the patient’s own description of his/her job
functions).
______________________________________________________________________________________________
______________________________________________________________________________________________

10. Describe other relevant medical facts, if any, related to the condition for which the patient seeks leave (such medical
facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized
equipment). DO NOT INCLUDE DIAGNOSIS IF PATIENT IS IN CA OR CT:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________

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Employee Name: Patricia J. Khan
Claim Number: 30204551727-0001
Medical Records/Form Due Date: 03/22/2020

SECTION 2: REQUIRED INFORMATION TO SUPPORT DISABILITY BENEFITS (will not be considered for
FMLA (Family Medical Leave Act) leave only determination)
1. Objective findings: HT: WT: BP: TEMP: PULSE: RESP:
2. Patient’s Complaints:

3. Your Diagnosis: (list all disabling diagnoses including all ICD codes)
Primary: ICD Code: _______________ Description: ______
Secondary: ICD Code: _______________ Description:
ICD Code: _______________ Description:
4. List all co-morbid conditions:

5. Describe objective/clinical findings to warrant disability, including severity and duration based on the
patient’s presentation during office visits.

_______
6. When was patient first diagnosed with this condition? _____/_____/_____
7. When is the patient’s next office visit? _____/_____/_____
8. Have there been any Emergency Room visits OR Hospitalizations during this current disability period? Yes  No 
If “Yes”:  Emergency Room visit  Hospitalization  23 hour admission
Name and address of hospital or facility

9. List all medications, identify dates of new medications or dose adjustments: (attach list if necessary)
Medication Dose Frequency Duration New Med Adjusted Med Date Adjusted
Yes  No  Yes  No  ___/_____/_____
Yes  No  Yes  No  ___/_____/_____
Yes  No  Yes  No  ___/_____/_____
Yes  No  Yes  No  ___/_____/_____
10. Is this condition the result of an injury? Yes  No  Is this condition work related? Yes  No 
If “Yes”, provide date and description of event:
_____________________________________________________________________________________
_____________________________________________________________________________________
11. If patient is pregnant, is a C-Section planned?Yes  No  If “Yes”, date scheduled? _____/_____/_____

12. What is the prescribed treatment plan? (please provide specific details regarding treatment/therapy, attach
notes if necessary):

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 13. Has any surgical procedure related to current disability been performed or is any anticipated?Yes  No 
List the name of the procedure:
CPT code: Date of procedure: _____/_____/_____
14. Has patient been referred to other physician(s)/specialist? Yes  No  If “Yes”, provide physician
name, specialty, and telephone number.

15. List specific functional limitations of Activities of Daily Living (ADL’s):

16. Has patient been given any driving restrictions for this disability period? Yes  No 
If “Yes” please describe:

Please attach all office notes, History & Physical, results of x-rays, laboratory tests, MRI Reports, etc, if relevant.

Physician’s name and title (please type or print) _______________________ __________ _______________________________
Specialty _______________________________ _________ Telephone _____ ________________Fax____ _ _____
Office Address ______________________________________________________________________________________________
Date form completed ___ Signature __________________________________________________

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