Notice of Charges for Completion of Forms

We receive many requests for completion of forms. This requires extra work, time and financial resources in excess of what is normally needed to complete the medical record. The fee must be paid when you drop off the form(s), or if they are being faxed or mailed to our office, please pre-pay before they are completed.

Please submit your request for completion of forms well in advance of when they are needed. We will attempt to complete the forms as quickly as possible however, in order to properly address them we need adequate time to review your records.

We require payment for the completion of the following forms that you ask us to complete on your behalf:

Type of Form Charge
STD – Short Term Disability (employer provided) $10.00
STD – Short Term Disability (supplemental policy) $10.00
LTD – Long Term Disability (employer provided) $10.00
LTD – Long Term Disability (supplemental policy) $10.00
FMLA – Family Medical Leave Act (standard form) $10.00
FMLA – Family Medical Leave Act (non-standard form) $10.00
Attending Physician Statement $10.00
Auto Insurance Attending Physician $10.00
PA Game Commission $10.00
Federal Family Education Loan Discharge $10.00
Bank/Credit Card Payment Deferral $10.00
Fitness for Duty $10.00
Medicare Patient (works part-time) $10.00
Life Insurance Application $25.00
ADA – Americans with Disabilities Act $25.00
School Medical Excuse No Charge
Crime Victims No Charge
Parking Placard Application No Charge
County Assistance Employability No Charge
County Assistance Health/Medication No Charge
Nursing Home Update/Order No Charge