Submit Disability/FMLA

To Complete a Disability/FMLA Form:

1. Please click the link below to begin the disability/FMLA form process; Please DO NOT bring forms to the practice to turn in.
2. Make sure to have your disability or FMLA form with you BEFORE logging in! (You should have received these forms from your disability carrier or employer). No forms are provided on this link.
3. Normal turnaround time to receive your completed form is 5 business days. There is an additional fee for expedited requests.
4. You will be asked for payment on this page as well. The cost is $25 per form, $20 for an updated form and $45 for an expedited request (guaranteed 3 day turnaround).
5. FMLA and Disability forms cannot be completed on the same request. These forms must be submitted separately.
6. For any further questions, please contact us at (413) 384-5279 or [javascript protected email address]

Click Here to Upload & Process Your FMLA or Disability Form

If you need any of the forms below completed, please drop these off at the “Information desk” in our lobby at our Birnie location, 300 Birnie Ave Springfield, MA 01107. Do NOT submit these via the link above.

• ADA Accommodation forms
• Aflac Accidental Injury Claim Form- Physician’s Statement
• AIG form for Travel Guard travel insurance claim form
• Applications for Disabled Parking Placard/Plate
• Arch Insurance Attending Physician’s Statement
• Baystate Health Request for provider information for an ADA accommodation
• Department of Unemployment Assistance
• Eversource Certification of Serious Illness
• Eversource Financial Hardship Form
• Hampden County Sherriff’s Department and Correctional Center Statement of Attending Physician
• Massachusetts Department of Transitional Assistance
• Request for Reasonable Accommodation
• Securian Financial
• All other Travel Insurance claim forms