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Medical Leave Extension Form

This document is a Medical Leave of Absence Extension Form for an associate named Joshua Long, requiring additional information from the attending healthcare provider to extend his disability leave. It requests details such as medical diagnosis, treatment plan, and dates related to the patient's disability and return to work. The form must be completed and returned to HR XPRESS to ensure proper processing of the leave extension and potential short-term disability benefits.

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63 views1 page

Medical Leave Extension Form

This document is a Medical Leave of Absence Extension Form for an associate named Joshua Long, requiring additional information from the attending healthcare provider to extend his disability leave. It requests details such as medical diagnosis, treatment plan, and dates related to the patient's disability and return to work. The form must be completed and returned to HR XPRESS to ensure proper processing of the leave extension and potential short-term disability benefits.

Uploaded by

jjlong713950
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

MEDICAL LEAVE OF ABSENCE EXTENSION FORM

To be completed only if you expect to be disabled beyond the approval date indicated on your leave status letter.

ASSOCIATE INFORMATION
Associate’s name: Joshua Long
AIN: 996180175
HRC9462773

ATTENDING HEALTH CARE PROVIDER'S INFORMATION


To extend the above Associate’s time off and/or period of disability under our short term disability plan, we need additional
information from you. Please complete all applicable sections of this form and return it to HR XPRESS at the address
provided at the top of this form. Lack of information may impact our ability to extend time off and/or approve payment of
additional short term disability benefits to your patient.

Please provide current medical diagnosis causing disability (include ICD-10 code(s)): _____________________________

_________________________________________________________________________________________________

Please provide current treatment plan: __________________________________________________________________

_________________________________________________________________________________________________

Please provide date of treatment with a specialist since / / .

Next appointment date: / / .

Date of Total Disability: From / / To / / .

*Date patient able to return to work / / .


*An "unknown" date will impact benefit payments

If patient has restrictions upon returning to work, please provide a detailed explanation:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Date restrictions start: / / .

Date restrictions will end: / / . Restrictions will be re-evaluated on : / / .

Name and Specialty of Provider: (Please print) : _______________________________________________________

Address: Street, City, State, Zip Code: _______________________________________________________________

Physician’s Signature: ______________________________________________________ Date: / / .


Revised 04/2025

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