If you are having a surgical procedure and need FMLA or Short Term Disability paperwork filled out, please complete the form below.

Please DO NOT bring forms to the practice to turn in.
Make sure to have your disability or FMLA form with you BEFORE submitting this form (You should have received these forms from your disability carrier or employer). No forms are provided on this link.
Normal turnaround time to receive your completed form is 5 business days.
You will be asked for payment after you submit these forms on the next page. The cost is $75 per form, $50 for an every additional updated form.
FMLA and Disability forms cannot be completed on the same request. These forms must be submitted separately.
For any further questions, please contact us at 502-409-6898 (option 5) or FMLA@handandwristlouisville.com

Name

First Name

Last Name

Phone

(###)

###

####

Email

Date of Birth

MM

DD

YYYY

Date of Last Office Visit

MM

DD

YYYY

Date of Surgery

MM

DD

YYYY

Type of Surgery

FMLA Carrier (who will the forms be coming from):

Short Term Disability Carrier (if applicable):

Date when forms need to be submitted by:

MM

DD

YYYY

Additional Information

Paperwork Request