Marietta Ob-Gyn Affiliates, P.A.
FMLA and Medical Disability Leave Forms
A minimum of 72 hours is required to complete forms. Emergency issues will be handled in a priority manner. All effort will be made to complete as quickly as possible.
You must complete all patient requested information and remember to sign and date. Please do not complete any portion of the physician section.
Turn your paperwork in to the check out desk. Do not give paperwork to your doctor, as this can cause a delay in completion. Upon turning in your papers, please provide the office with your preferred method of distribution once they are completed, i.e., pick up in office, mail or fax to you or the company requesting the information.
Marietta OB-GYN has partnered with MediCopy to fulfill your Release of Information requests and Disability/FMLA forms. MediCopy is fully HIPAA compliant and adheres to all state and federal regulations concerning release of medical information.
To request your medical records of forms completed please select from the following:
- Authorization for the Release of Medical Records (Online)
- Authorization for the Release of Medical Records (Paper)
Patients can request copies of their medical records at no cost, but delivery fees apply for postage. Please provide an email address on the authorization to expedite the process and delivery method. Records sent to another provider are complimentary. Requests are completed within two (2) business days after receipt by MediCopy.
Forms are $30 for the first form and $15 for each additional form turned in at the same time. After payment is received, Disability/FMLA forms are completed and sent to the requestor within three business days.
By law, we are required to have a signed authorization from all patients prior to disclosure of their medical information to any outside source. Most disability or FMLA forms include an authorization to disclose information page or paragraph to be signed by the patient. If your paperwork contains this, please be sure to carefully read and complete that section by signing and dating where indicated.
If your forms do not include an authorization page or section, you will be required to sign our office authorization form prior to completion or release of these forms to anyone, including you. Please note, this includes FMLA for your Spouse or relatives as well. We must have an authorization from the patient before any medical information will be given. The office authorization page can be found here.
Just a reminder, if your employer offers FMLA benefits, you are entitled to 12 weeks time off for the birth of a child. However, our office only allows six weeks medical disability for vaginal deliveries and eight weeks for C-Section deliveries. Any additional time off is between you and your employer.
Any questions, please contact Diana Bautista at (770) 422-8505 Ext 130