FMLA/Disability - Illinois CancerCare

Request for Completion of Disability, FMLA, or Other Clinical Paperwork

Please note: Forms require up to 14 days for processing. Leaving portions of this form blank could result in a delay in processing.

Patient Information

Patients Name

First Last

Date of Birth

Phone

Family Members Name (if applying as a caregiver)

First Last

Family Members Phone

Forms

What type of form needs completed?

FMLA

Disability

Other

FMLA

FMLA is a law that protects your job. If you meet criteria, it allows you to take up to 12 weeks off to manage a serious illness or provide care for a family member. FMLA time can be taken all at once (a single continuous leave) or only when it’s needed (intermittent leave).

I would ike to take:

Intermittent Leave

A Single Continuous Leave

What date should FMLA time begin?

What date should FMLA time end?

Disability

Disability is an insurance policy that can either be short-term or long-term and provides a replacement for income in the event of illness or injury. Eligibility is dependent on whether you have participated in this policy through your employer.

My last day worked was:

Planned date to return to work:

NOTE: If you are seeking Social Security Disability, you must first contact the Social Security Administration.

Other

Please provide any necessary information required to complete:

Additional Documents

File

Max. file size: 50 MB.

Form Delivery

How would you like the forms delivered?

Fax

Pick-up

Mailing Address

Fax Number

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country