![]() ![]() ![]() Be sure to enter the disability claim number on the Intake form. If the authorization is not signed, the completed form will be sent to you, the patient. Authorization must be provided on the intake form in order to release records to anyone other than you, the patient. INCLUDE a completed Intake form (PDF) to initiate your STD/LTD request. Submit the form provided to you by your disability carrier, Please refer to your employer for additional details. Benefits are provided through your employer, and Kaiser Permanente supports authorization of these benefits. These plans pay you a portion of your income for a short period, which is defined by your disability plan. Some employers may require you to apply for FMLA at the same time as STD or LTD (please consult your employer for details). Short-term and long-term disability coverage protect employees when they are off the job for a period of time due to illness or injury. If any of the above requests need to be modified after they have already been approved, please contact your clinical team to have your work status updated. If your employer requires a Return to Work release click here for information on how to obtain that release. Mail: Kaiser Permanente Release of Information Departmentġ0220 SE Sunnyside Road, Clackamas, OR 97015 IF you are also submitting a disability form, please enter the claim number on the intake form.įorms submitted with incomplete information will significantly delay processing of your request.įor the fastest service, scan your completed form(s), attach to an email and send to you can: IF you are also submitting a disability request, follow instructions and complete all fields on the intake form for both FMLA and short-term or long-term disability, as applicable to you request. If the authorization is not signed, the completed form will be sent to the patient. Intake form (PDF) to initiate your FMLA request. Recertification: If you need either of the above leave types recertified or renewed please contact the Release of Information department to initiate your request. You will need to provide details of the episodes related to your condition. Intermittent: for example, chronic flare-ups of a condition result in several absences from work over the course of a month. Refer to your employer for details on your organization’s policies on timing for requesting FMLA.Ĭontinuous: For example, you are absent from work for more than 3 consecutive days (e.g. The Family and Medical Leave Act (FMLA) covers leave for your absence from work due to your own care or to care of an eligible family member or loved one under state and/or federal law. ![]()
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