Additional Fees: 

 

For any disability or FMLA forms to be processed and subsequently completed by the provider, the following must be submitted to the Advanced Practice Headache Clinic by fax, postal mail or in person:

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• A Disability/FMLA/Special Reports Request form

 

• Headache Calendars for the past three months (not applicable for new patients requesting FMLA)

 

• A signed and valid ROI (release of information) authorization to release medical information to a third party (if applicable)

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What Fees Are Charged?

 

A non-refundable $10 administrative fee will be charged for all disability/FMLA form requests. This fee will be charged to the credit card number provided on the Disability/FMLA Request form.

 

Before any disability and/or FMLA forms are completed by your provider, a forms fee will be charged to the credit card number provided on the Disability/FMLA Request form. This fee varies according to the length of the form, and will not include the cost of sending any additional records (if requested). Typically, the form fee is in the range of $50 – $100, which includes the $10 non-refundable administrative fee.

 

The form fee applies only to basic forms and physician statements. For more detailed, multiple impairment questionnaires, the price is higher based on the number of pages.

 

How Long Does It Take?

 

• The processing time for disability or FMLA forms is 10 – 15 business days after all necessary forms are received at the Advanced Practice Headache Clinic. Failure to submit any of the requirements listed above will result in a delay in processing time or incompletion of forms.