AMAZON_START

RICOH USA, INC.

5575 Venture Drive Unit A
Parma, Ohio 44130

Attn: Sarah khalifa

56 Fillmore Avenue
Staten Island, NY 10314

5004o00000P8ZJHAA3
.
AMAZON_START

June 23, 2022

Sarah khalifa
56 Fillmore Avenue
Staten Island, NY 10314
USA

Action required: Leave decision – Sarah khalifa, Case 04259813

Sarah,

Your leave request has been denied. Review the details below and your right to an appeal.

Your Leave Case

 We have denied the following leave plans

Plan Name Start Date End Date

Federal FMLA May 19, 2022 June 2, 2022
Medical Leave of Absence May 19, 2022 June 2, 2022

Pay available during leave

On June 23, 2022 we have denied your STD benefits from May 26, 2022 to June 2, 2022 because

1. You failed to provide any documentation supporting that you have a disability.
The denial was made in accordance with the Amazon Short-Term Disability (STD) summary plan
description. For further details, see the Amazon STD summary plan description section below.

Required next steps

 In order to qualify for pay during your leave NY requires you to apply for paid benefits at or
Phone: .
 You must submit your state benefit decision letter to Amazon within 5 calendar days of receipt
by
o A to Z: atoz.amazon.work, navigate to the Resources link in the footer and select the
Leave of Absence and Accommodations tile.
o Disability and Leave Services (DLS) Portal: https://dls.idp.amazon-corp.com (on the
Amazon network)
o Replying to this email

Your right to an appeal

 You have the right to appeal your STD benefits denial.
 To appeal, submit a written request with supporting documentation within 180 calendar days
of the date of this letter. Send your appeal request by email to amazondls@amazon.com.
  You will be notified of a decision on your appeal within 45 calendar days from when your
request for review is received. If special circumstances exist, this period may be extended by up
to an additional 45 calendar days.
 Upon request, you may have reasonable access to and copies of all documents, records, and
other information relevant to your claim.
 Your appeal request must include your name, Amazon’s name, your case number 04259813,
the reason for your appeal, and any new information or supporting documentation.

Important information you should know

 You can use available Sick, Personal, Floating Holiday and/or Vacation time to cover this unpaid
period. Enter available time off on Amazon A to Z via atoz.amazon.work or the DLS Portal at
https://dls.idp.amazon-corp.com (on the Amazon network).

Questions?
Visit the Resources page at atoz.amazon.work, contact us by emailing amazondls@amazon.com or
calling 888-892-7180, Option 1 for leave services, then Option 2.

Your feedback is valuable and helps us improve the employee experience for all Amazonians. Visit this
site to let us know how we're doing.

Thank you,
Amazon DLS

Amazon short-term disability (STD) summary plan description (SPD)

1. You failed to provide any documentation supporting that you have a disability.
1a. Initial
Per the STD SPD:
Section 6: Claims Steps for Filing a Claim for Benefits
…Provide DLS satisfactory Proof of Disability no later than either (1) 30 days after the date of the
request/notice, or (2) 30 days after the end of the Date of Disability. Proof must be provided to DLS at
the employee’s expense. In some circumstances after an Employee’s request is denied, the Plan may
accept the Satisfactory Proof of Disability up to 15 days after the initial due date, without requiring a
formal appeal.
Failure to furnish such Proof within such time shall not invalidate or reduce any claim if it was not
reasonably possible to furnish such Proof within such time (e.g., due to your incapacity). Such Proof
must be furnished as soon as reasonably possible and, in no event, except in the absence of your legal
capacity, later than one year from the time Proof is otherwise required.
Provide DLS satisfactory Proof of continued Disability, when applicable, and Regular Attendance of a
Health Care Provider within 15 days of any request.
DLS reserves the right to determine if your Proof of Disability is satisfactory.
Respond to all inquiries in a timely manner. Failure to provide the necessary information may result in
denial or termination of Benefits.
"Proof" means the evidence in support of a claim for Benefits and includes, but is not limited to, the
following:
1. A claim form completed and signed (or otherwise formally submitted) by you claiming
Benefits;
2. An attending Health Care Provider’s statement completed and signed (or otherwise formally
submitted) by your attending Health Care Provider; and
3. The provision by the attending Health Care Provider of standard diagnosis, chart notes, lab
findings, test results, x-rays and/or other forms of objective medical evidence in support of a
claim for Benefits.

The following information was reviewed to make the denial determination:

 No documentation received.

End STD Denial reasons

STD FAQ

STD FAQ
STD FAQ lists additional questions and answers regarding Amazon's Short-Term Disability policy
Translation Information

Translation Information
Translation Information lists languages available for translation
Benefits During LOA Guide

Benefits During LOA Guide

Benefits During LOA Guide lists all resources and information for leave of absence
 Return Fax Cover Sheet
Return Fax Number: 1-855-579-1799
Employee: Phone:

Case Number:

Comments:

If you have any questions or concerns, please contact Disability & Leave Services (DLS) by emailing
amazondls@amazon.com or calling (888)892-7180.

NOTE: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers from requesting or requiring genetic information
of employees or their family members. Please do not provide any genetic information when responding to this request for medical
information. Genetic information is defined in 29 CFR. § 1635.3.
Do not provide information about genetic tests, as defined in 29 C.F.R. § 1635.3(f), genetic services, as defined in 29 C.F.R. § 1635.3(e), or the
manifestation of disease or disorder in the employee’s family members, 29 C.F.R. § 1635.3(b).
 Health Care Provider Form – Leave as an Accommodation
Return this form by fax to 1-855-579-1799 or by email to amazondls@amazon.com.

 Instructions for Healthcare Provider: Complete Sections A-D as applicable with the medical facts to support this
employee’s request for leave as an accommodation. Please indicate “not applicable” in any section where the
question is not relevant to the condition or impairment, or where the information would not be relevant to our
evaluation of your patient’s need for a job accommodation.

Employee Name: Sarah khalifa Employee Date of Birth: February 28, 1989
Employee Job Title: Fulfillment Associate Case Number: 04259813
Requested Leave Start Date: May 19, 2022 Requested Return To Work: June 3, 2022

Section A: Leave Request Information (to be completed by the Health Care Provider)_____________________
A1. Is/was it necessary for your patient to miss work due to a disability or medical impairment?  Yes  No
A2. Can the patient safely continue working their current job while we evaluate accommodation options?  Yes  No
A3. First visit date: ____/____/____ Last visit date: ____/____/____ Next office visit date: ____/____/____
A4. Select the type(s) of leave that is required due to the impairment or disability:
 Continuous Leave (one single uninterrupted absence from work)
Leave Start Date: _____/_____/_____
 Intermittent Leave (multiple absences from work for the same disability or impairment over a period of time,
provide best estimate if unknown)
First Date of Absence: _____/_____/_____ Certification End Date: _____/_____/_____
_____ number of absences per  day  week  month  year
_____ number of hours or days (circle one) per absence

Section B: Patient’s Impairment (to be completed by the Health Care Provider)______________________

B1. Does the employee have a disability or impairment that limits their ability to perform their job duties?
 No (assumes general illness/injury not rising to the level of impairment or disability)
 Yes
If yes, what major life activities or major bodily functions are affected by the disability, impairment, or
treatment/medication (such as walking, breathing, concentrating, etc.)? Please do not disclose the medication
or type of medication.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
B2. Was the disability or impairment sustained while the patient was performing their job?  Yes  No
 Form continues on next page.

B3. Is this absence from work related to the employee’s pregnancy, or recovery from childbirth or pregnancy loss?
 Yes, with due date _____/_____/_____  Vaginal delivery  Cesarean

 Yes, pregnancy loss; loss date _____/_____/_____ at week _______ of gestation

 No
B4. What is the anticipated duration of the disability or impairment? (If the recommendation for accommodation is for a
different duration than the disability or impairment, please specify in question B6.)
 Short term (1-3 months) from: _____ /______ /______ to: _____ /______ /______
 Medium term (3-6 months) from: _____ /______ /______ to: _____ /______ /______
 Long term/Permanent (6 months or more)
 Unknown. When do you expect to be able to make a determination? _____ /______ /______
B5. What specific job responsibilities is the patient having trouble performing because of the disability or impairment?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
B6. What accommodation(s), if any, do you recommend? (Identify possible accommodation(s) that may enable the
patient to perform the essential job functions. Please include any therapeutic devices or activities you recommend.
Include duration of accommodation if different than duration of condition specified in question B4.)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Section C: Return to Work Planning (to be completed by your Health Care Provider)_____________________
C1. Per your assessment, is your patient fit to return to work?
 Yes, fit to return full duty with no restrictions on _____/_____/_____
 Yes, fit to return full duty with restrictions on _____/_____/_____ (Please complete question B6 in Section B.)
 No, cannot return to work at this time (Amazon will provide a separate form for return to work planning.)
Section D: Certification by the Provider________________________________________________________
 I certify that the information contained on this form and submitted with this form is true and correct.

Provider’s Name and Credentials (MD, DO, Type of Practice Telephone Number
etc.)

Office Address (Street, City, State, Zip Office Hours Fax Number
Code)

/ /
Provider’s Signature Date

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 or an individual’s family members’ 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.
 Authorization to Obtain and Disclose Information
 Instructions for Employee: Complete and return to Amazon Disability & Leave Services (DLS).
 Return the form: Upload the completed form to the DLS Portal, found on the Amazon AtoZ Resources page or at
dls.idp.amazon-corp.com (while on the Amazon network). You can also email to amazondls@amazon.com or fax to
1-855-579-1799.

Employee Name: Sarah khalifa Employee Date of Birth: February 28, 1989
Employee ID: 104542321

This Authorization is being provided so that Amazon and any of its parents, affiliates, subsidiaries, and/or third-party
contractors; Aetna Inc. (Aetna), and any of their parents, affiliates, subsidiaries, and/or third-party contractors; The
Hartford, and any of their parents, affiliates, subsidiaries, and/or third-party contractors; Amazon Corporate LLC
(together with any of its Affiliates or Subsidiaries (Amazon); WorkCare, and any of its parents, affiliates, subsidiaries,
and/or third-party contractors; and/or Sedgwick Claims Management Services, Inc. (Sedgwick CMS) can obtain the
necessary information to adjudicate a claim for disability or workers’ compensation benefits, or a request for leave of
absence or related benefits, initiated by or on behalf of the Patient identified above (“Patient”). Once this Authorization
is completed and signed by the Patient (or Patient’s guardian) whose personal health information is to be disclosed, the
health care provider should retain the original for its records and provide a copy of the Authorization to the Patient.
Patient can submit completed document via the DLS Portal, by faxing to 1-855-579-1799, by emailing
amazondls@amazon.com, or by mail to Amazon Disability & Leave Services (DLS), PO Box # 81103 Address: 5801 Postal
Road, Cleveland, Ohio 44181.
To: Any health care provider, Pharmacy Benefit Manager, employer, benefit plan, insurer, financial institution, consumer
reporting agency, educational institution, or federal, state, or local government agency, including the Social Security
Administration and Veterans’ Administration.
By signing the Patient Authorization below, your Patient has authorized you to disclose to Amazon, Aetna, The Hartford,
WorkCare, or Sedgwick CMS a complete copy of any and all personal or privileged information, records, or documents
described herein.
Information covered by this authorization: Any and all medical (but not genetic) information or records, including X-ray
films, prescription histories, medical histories, physical, mental or diagnostic examinations, and treatment notes, and
including information regarding HIV/AIDS, communicable diseases, alcohol or drug abuse, and mental health, as such
information may be related to the Patient’s claim for benefits; work information and history, including job duties,
earnings and personnel records, and client lists; information on any insurance coverage and claims filed, including all
records and information related to such coverage and claims; Social Security benefits information, including monthly
benefit amounts, monthly payment amounts, entitlement dates, and information from my Master Beneficiary Record.
The information obtained by use of this Authorization will be used to evaluate and administer the Patient’s claim for
benefits under the employer’s plan for short-term disability benefits or long-term disability benefits insured by Aetna or
The Hartford, to administer the Patient’s claim for workers’ compensation benefits, and/or a request for leave of
absence or related benefits. Such information is referred to in the Patient Authorization as “My Information.”
PATIENT AUTHORIZATION
I authorize Amazon, Aetna, The Hartford, WorkCare, or Sedgwick CMS to use or disclose My Information as necessary to
administer my claim for short-term disability benefits and/or workers’ compensation benefits and/or leave of absence
or related benefits. I also authorize Amazon, Aetna, The Hartford, WorkCare, or Sedgwick CMS to disclose My
Information as follows: (i) to Amazon for (a) functions related to accommodating my medical restrictions or limitations;
(b) federal or state Family & Medical Leave Act administration; (c) administration of related leave or benefits
claims;(d)fulfilling fiduciary obligations under my benefit plan or (e) responding to legal claims against Amazon or its
agent; (ii) to the administrator or other service providers of Amazon’s benefit plan or other benefit plans of my
employer for plan-related functions; (iii) to any system used for claims processing or insurance broker to carry out
functions related to my benefit plan or claim; (iv) to any health care professional who has treated or evaluated me or
who may do so; (v) to other persons or entities performing business or legal services related my claim or to other
benefits for which I may be eligible in the future; (vi) as may be lawfully required; (vii) as I may further authorize; or (viii)
as necessary to prevent or to detect perpetration of a fraud in connection with my application for benefits.
I authorize the disclosure of my personal and medical information as described above. I understand that this
authorization is voluntary. I understand that information disclosed pursuant to this Authorization may be subject to re-
disclosure by the recipient as permitted by applicable law or my further authorization. I understand that I have the right
to fully or partially revoke this Authorization for future disclosures from Amazon, Aetna, WorkCare, or Sedgwick CMS
may make, unless they have taken action in reliance upon this Authorization. If I decide to fully or partially revoke my
Authorization, I must revoke do so in writing directly to Amazon, specifying whether I wish to fully revoke my
authorization, or, if I wish to partially revoke my authorization, providing a description of the information and/or
purposes for which I am withdrawing my authorization. I understand that my medical treatment, payment for medical
benefits, or enrollment/eligibility for leave benefits cannot be conditioned on my allowing Amazon, Aetna, the Hartford,
WorkCare, or Sedgwick CMS to re-disclose My Information and that I may fully or partially revoke my authorization for
re-disclosure at any time.
This Authorization expires two years from the date listed below or earlier as required by law, or upon my revocation, if
earlier, but will not exceed the term of my coverage of the policy or benefit plan. I understand that I am entitled to
receive a copy of this Authorization upon request. A photocopy or facsimile of this Authorization shall be as valid as the
original. If there is a conflict between a prior request for restriction on the disclosure of My Information and this
Authorization, this Authorization will control.
Note to employee/beneficiary: In order to be considered for short-term disability or workers’ compensation benefits,
you must authorize disclosure of personal and medical information as needed to determine whether you qualify for
those benefits. If signed, this form would also authorize further disclosure of your information in order to expedite
consideration of your eligibility for additional benefits in the future. Such additional benefits might include long-term
disability benefits, vocational rehabilitation services, and payment of life insurance premium while you are on leave. You
are not required to authorize disclosure or re-disclosure of your personal or medical information for such additional
purposes. If you do not want this release to authorize such additional disclosure, please contact DLS at 1-888-892-7180.
Important Information for Your Health Care Provider About GINA
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.

______________________________ _____________________________________ _______________

Signature of Patient or Guardian Relationship to Patient (if signed by guardian) Date Signed
New York PFL Statement of Rights

New York Paid Family Leave Statement of Rights

New York PFL Statement of Rights includes information for paid family leave for New York