Disability and FMLA Forms

Please complete the following information in its entirety.

Payment of $20 per form is required for forms to be processed for all Pennsylvania patients (no charge for New Jersey patients, as per state mandate).

In order to protect your privacy, online requests for disability and/or FMLA forms can only be sent directly to a patient’s home address or state disability agency.

Requests that fall outside of the above mentioned categories require a hard copy signature in addition to the online submission. A physical HIPPA form can be obtained and signed in any office or can be mailed, faxed or emailed to you.

Please contact us with any questions at 1-800-321-9999.

Fields marked with (*) are required

First Name(*)
Please enter your first name

Last Name(*)
Please enter your last name

Rothman Institute Account # (if known)
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Date of Birth(*)
Please enter your date of birth

Please enter a valid phone number

Please enter a valid email address

Rothman Institute Physician/Provider (*)
Please enter your Rothman Institute Physician/Provider

Date of First Day out of Work (actual or anticipated)(*)
Please enter your Date of First Day out of Work (actual or anticipated)

Estimated Return to Work Date(*)
Please enter your Estimated Return to Work Date

Disability Insurance Company (*)
Please enter your Disability Insurance Company

Please enter your Employer

Form Type(*)
Please select Form Type

Upload Form
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If your form is not listed above, please upload it here, or fax it to 267-479-1321

NOTE: Only PDF files, maximum 5MB size

Completed forms should be returned to (*)

Please select the recipient of the Completed Forms

Submit Form Via(*)

Please select Submit Form Via

Fax Number(*)
Please enter the fax number where you would like these forms submitted

Please enter the email where you would like these forms submitted

Mailing Address(*)
Please enter the mailing address where you would like these forms submitted


In the event that any of the foregoing information contains mental health records, genetic information, venereal disease-related records, tuberculosis-related records, drug and alcohol treatment records, and/or HIV/AIDS-related diagnosis and treatment information, I specifically authorize release of such information (By checking this box you agree)

Please check the box in order to submit the request
Purpose or reason for request(*)

I knowingly and voluntarily authorize the Rothman Institute and its employees and agents to use and/or disclose protected health information (PHI) about me in the manner described in this authorization. (If you are a patient, you may type “my personal request” in the box below.)

Purpose For Request Required
This authorization will expire on(*)
Please enter an expiration date

Payment Method(*)
Please select a payment method

Payment Instructions:

  • If you are paying by Credit Card, you must follow the link that will be provided after you submit this form.
  • If paying by check, please make check payable to "Reconstructive Orthopaedic Associates" and mail to:
    Rothman Institute
    925 Chestnut St., 5th Floor
    Philadelphia, PA 19107

    Please include in the check memo "Disability Forms" and your account number, if known


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