Are You Eligible?
In order for your provider to complete any forms regarding your disability status, you must have received treatment at the Diamond Headache Clinic within the last three months. To be eligible for disability benefits that are supported by the Diamond Headache Clinic, you must first complete at least three office visits with your current provider.
What Is Required?
For any disability or FMLA forms to be processed and subsequently completed by your provider, the following must be submitted to the Diamond Headache Clinic by fax, postal mail or in person:
- Any disability or FMLA forms that need to be completed by your provider
- A Disability/FMLA/Special Reports Request form
- Headache Calendars for the past three months (not applicable for new patients requesting FMLA)
- A signed and valid ROI (release of information) authorization to release medical information to a third party (if applicable)
The required forms are available at our clinic or you can download them from our website by clicking on the links above.
What Fees Are Charged?
A non-refundable $10 administrative fee will be charged for all disability/FMLA form requests. This fee will be charged to the credit card number provided on the Disability/FMLA Request form.
Before any disability and/or FMLA forms are completed by your provider, a forms fee will be charged to the credit card number provided on the Disability/FMLA Request form. This fee varies according to the length of the form, and will not include the cost of sending any additional records (if requested). Typically, the form fee is in the range of $50 – $80, which includes the $10 non-refundable administrative fee.
The form fee applies only to basic forms and physician statements. For more detailed, multiple impairment questionnaires, the price is higher based on the number of pages. The price for a detailed narrative report is $500. We do not bill insurance for completion of any narrative reports, physician statements or questionnaires pertaining to disability/FMLA.
How Long Does It Take?
The processing time for disability or FMLA forms is 10 – 15 business days after all necessary forms are received at the Diamond Headache Clinic. Failure to submit any of the requirements listed above will result in a delay in processing time or incompletion of forms.