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Number of Forms: ___ Total Due: ___ Payment Received:Office: 8165252840 | Fax: 8165252841YES or NOFMLA & SHORTTERM DISABILITY The fee for FMLA and shortterm disability paperwork is $25 and due prior to processing. Our goal is to process your form expediently. Provider will complete paperwork 7 10 business days after surgery. If patients employer needs something prior to the date of surgery, a letter can be provided. Patient Name:Date of Birth:Address:City:Email:StateZip:Phone:Physician:First

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