Disability Form Completion Policy

Is this a continuous amount of time you plan on being out of work or is this an intermittent leave to attend physical therapy/appointments?

Continuous

Intermittent

For patients requesting FMLA

NHOC Physician:*

Name of Employer:*

Date of Injury or onset of symptoms:*

Date last worked/anticiapted out of work date:*

Who took you out of work?*

Job Description:*

Usual hours per day:*

Usual hours per week:*

My position requires me to:*

When disability form is completed:*

Please email completed form to me

NHOC will fax the completed form to Employer or Insurance Company

Please send a completed copy of the disability form to my NHOC Patient Portal

Number to fax form*

Attention:*

Email to send form to*

Please be sure to ask for an updated work note at each follow up visit. The note needs to indicate if you are returning to work including a return to work date or if you are to continue to remain out of work with anticipated return to work date.

Patient or Authorized Signature:*

Relationship to Patient:*

Date:*

Phone

This field is for validation purposes and should be left unchanged.

	Frequently	Occasionally
Bend
Kneel
Squat
Climb Ladder
Climb Stairs
Stand
Walk
Sit
Reach Left arm
Reach Right arm
Drive
Perform fine motor skills
Lift 5lb-10lb
Lift 10lb-25lb
Lift 25lb and greater

Is it time to schedule your appointment?