All form fields are required. If you have any questions please call our office 414-384-6700.

Use or Disclosure Patient Authorization

Personal Information Disclosure

Patient Information

First Name(Required)

Last Name(Required)

Date of Birth(Required)

Physician(Required)

Mobile Number(Required)

Email(Required)

Facility Information

Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP

All form fields are required. If you have any questions please call our office 414-384-6700.

Use or Disclosure Patient Authorization

Information Disclosure

The following information may be used and disclosed:(Required)

(Specifically describe the information to be used and disclosed, including meaningful descriptors such as date of service, type of service provided, level of detail to be released, origin of information, etc.)

The Facility may disclose this protected health information to:(Required)

(Insert name of person or entity who may receive the information.)

This protected health information is being used or disclosed for the following purposes:(Required)

(List specific purposes here, the patient may indicate that the information to be disclosed is “at the patient’s request” if the patient does not choose to provide an explanation of the purpose of the request, simply check the box below.)

At Patient's Request

This authorization shall be in force and effect until:(Required)

(check one of the following)

A Specific Date

The happening of the following event

End of research study at which time this authorization to use or disclose this protected health information expires.

No expiration (can only be used if authorization is for creation of research database or research repository.)

Authorization Until This Event(Required)

Authorization Expiry Date(Required)

All form fields are required. If you have any questions please call our office 414-384-6700.

Use or Disclosure Patient Authorization

Authorization

I understand that I have the right to revoke this authorization, in writing, at any time by sending written notification to:

Facility Name
Address
City, State ZIP
ATTN: Privacy Officer

I understand that a revocation is not effective to the extent that the Facility has relied on the use or disclosure of the protected health information.

I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.

I understand that the Facility will not condition treatment, payment, enrollment in a health plan or program, or eligibility for benefits on whether I provide this authorization.

Third Party Name(Required)

I understand that if the Facility requested this authorization, the Facility must provide me with a copy of this form once it has been signed. I understand that I have the right to refuse to sign this authorization.

Enter your Full Name(Required)

Today's Date(Required)

Name of Patient or Personal Representative(Required)

Description of Personal Representative’s Authority(Required)

All form fields are required. If you have any questions please call our office 414-384-6700.

Form Upload

Instructions

READ THIS BEFORE CONTINUING:

You will be required to upload your Disability/FMLA form, which might have one or more pages.
If your form is electronic already, such as a PDF document, you will be able to upload it from your device.
If your form is a paper form, you must take pictures of each form page or scan each form page first.
You must review the pictures/scans to ensure acceptable image quality. We will type directly onto the form pages you supply.
Your completed disability/FMLA form will be faxed directly to your employer or insurance company.

INSTRUCTIONS FOR TAKING PICTURE(S):

Page(s) should face the correct direction (not upside down or sideways)
Page(s) should lie flat (smooth out any folds/creases in page)
Picture should be taken from above, straight down
Avoid as much shadow as possible
Avoid as much background (table, furniture, leg, etc.) as possible

Image Samples

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You will be asked to upload your form images later in the submission process.

If you are using a mobile device, there are free apps such as "TURBO SCAN™" that will take near-perfect images of your form pages.

YOU ARE SOLELY RESPONSIBLE FOR THE FOLLOWING:

CHOOSING THE OPTION TO DELIVER TO A PERSON/THIRD PARTY AT THE TIME YOU PLACE YOUR ONLINE REQUEST.
PROVIDING DELIVERY INFORMATION AT THE TIME YOU PLACE YOUR ONLINE REQUEST.
ENSURING THAT THE DELIVERY INFORMATION YOU PROVIDE IS COMPLETELY CORRECT.
CONFIRMING RECEIPT OF THE COMPLETED FORM BY THE PERSON/THIRD PARTY YOU DESIGNATED.

WE ARE NOT RESPONSIBLE FOR ANY DENIAL OF BENEFITS DUE TO THE FAILURE OF THE PATIENT/PATIENT CAREGIVER TO CONFIRM TIMELY RECEIPT OF THE COMPLETED FORM BY THE DESIGNATED PERSON/THIRD PARTY.

PLEASE ACKNOWLEDGE YOUR ACCEPTANCE OF THESE PATIENT RESPONSIBILITIES BEFORE CONTINUING:

All form fields are required. If you have any questions please call our office 414-384-6700.

Form Upload

Upload ID and Disability / FMLA Form

Instructions for submitting your form

Due to the very high volume of patients who require FMLA and disability paperwork to be completed and signed by the doctor, we have implemented the following platform to assist in the rapid processing of these important and necessary forms. Through this platform, all FMLA and disability forms will be returned to you, digitally, within 7 business days, depending on the delivery option you choose. Once complete, your form(s) will be provided to you through a convenient, secure and efficient electronic platform. Your form(s) will also be stored in your electronic chart at the Orthopedic Institute of WI and you will have personal control and access to your form(s) that you will now own. For any questions, please call 414-384-6700.

INSTRUCTIONS:

This site is for patients or their caregivers who need a form completed to apply for disability benefits or employer leave.
An FMLA or Disability Form can be made up of one page or multiple pages. For each type of form (regardless of how many pages the form has), you must submit a new and separate form request through this site. For example, if you need us to complete an FMLA Form and a Short Term Disability Form, then you have two separate forms and should repeat the request process from start to finish for each of the two forms.
IF YOU UPLOAD MORE THAN ONE FORM PER ONLINE SUBMISSION THEN YOUR FORM SUBMISSION WILL BE REJECTED.
Your form will be processed within 7 business days.
If you do not follow the online instructions, your form request might be delayed or rejected.
The processing time begins once we have received all necessary items: a Release of Information authorization, your ID, and one Disability/FMLA form.*

You will need the following:

A valid driver's license or other valid state-issued ID.
A picture or PDF of your form ready to be uploaded*
The contact information of the recipient is where your completed form will be faxed to (e.g. an employer or insurance company)
Please have these items handy before you start!

*You should fill out any patient/caregiver sections of your form before submitting it to us.

All form fields are required. If you have any questions please call our office 414-384-6700.

Form Upload

Instructions

Please do the following:

Upload an image of your driver's license or other government-issued identification below.
Upload image(s) of your form in the same location below.
Note: Before submitting your form to us, make sure to fill out all sections that you, as the patient or caregiver, are required to fill out. If those sections are not completed, we cannot begin processing your form.

Please note the following:

The files you upload must be PDF, JPG/JPEG, TIF/TIFF, HEIC/HEIF, or PNG.
Uploaded files must be less than 20 MB in size.
This site will automatically log you out if you are inactive or switch away from your browser to another app for 10 minutes.

Upload Instructions

From a computer/laptop: Scan or photograph your ID and form. Save this file to your computer/laptop. Either click 'Drop Files to Upload' to drag the file(s) into the blue box below, OR click the 'Or Click Here' portion of the blue box, then browse your device to find your saved files and double-click the files to upload them.

From a mobile device (smart phone/tablet): Tap 'Touch Here to Take Picture/Upload'. Follow instructions to either take a picture of your ID and form or to find an already-saved file of your ID and form. They will upload automatically for you.

Upload File(s)(Required)

Drop files here or

Accepted file types: pdf, jpg, jpeg, tif, tiff, heic, heif, png, Max. file size: 20 MB.

Name

This field is for validation purposes and should be left unchanged.

Disability / FMLA Paperwork

Use or Disclosure Patient Authorization

Personal Information Disclosure

Patient Information

Facility Information

Use or Disclosure Patient Authorization

Information Disclosure

At Patient's Request

Use or Disclosure Patient Authorization

Authorization

Form Upload

Instructions

READ THIS BEFORE CONTINUING:

INSTRUCTIONS FOR TAKING PICTURE(S):

Image Samples

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Bad

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YOU ARE SOLELY RESPONSIBLE FOR THE FOLLOWING:

Form Upload

Upload ID and Disability / FMLA Form

Instructions for submitting your form

INSTRUCTIONS:

You will need the following:

Form Upload

Instructions

Please do the following:

Please note the following:

Upload Instructions