Submit Your Request

Complete all required fields. Our team will follow up within 2–3 business days to confirm your request and send an invoice.

ABOUT YOU

First Name

Last name

Date of birth

Month

Day

Year

Phone number

Email address

EMPLOYER & JOB INFORMATION

Employer name

Job title

Work schedule

Brief description of job duties

A brief description helps your provider assess functional limitations. 1–2 sentences is enough.

HR or leave administrator contact

Insurance carrier or disability carrier

Last day worked

Anticipated return date

Filing deadline

Rushed processing needed?

Attach STD forms in PDF format

Additional notes

PATIENT ACKNOWLEDGMENT

I am actively engaged in treatment at EKM Psychiatry and attending scheduled appointments.

I understand that submission does not guarantee documentation will be provided or that my claim will be approved.

I understand the $150 fee is due before work begins and is non-refundable once documentation has been initiated.

I understand initial documentation covers no more than 30 days and extensions are not automatically approved.

I have read and agree to EKM Psychiatry's Short-Term Disability Documentation Policy.

Signature

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By submitting this form and typing my name below, I certify that the information provided is true and accurate to the best of my knowledge. I understand that EKM Psychiatry will review my request in accordance with its Short-Term Disability Documentation Policy and that submission of this form does not guarantee approval of disability leave, completion of documentation, or approval of any claim by my employer or insurance carrier. I understand that my typed name constitutes my electronic signature.

Date

Month

Day

Year