Letter Request Form – John Naus, MD PA

Name *

First

Last

Date of Birth

Note: All letter requests may require 7 business days or more for completion. All letters that require a provider’s signature are subject to a fee as described in your treatment. Once submitted you will be contacted about your letter request and any fees associated with your request. If this letter relates to your work performance please be sure you have contacted your work Human Resources (HR) department to be sure a letter is needed. Often HR will need specific paperwork to be filled out to fulfill your request. Any letter request is considered independent of a request for completion of paperwork. These separate actions may incur separate charges. *

I understand and accept the above statement.

To receive a copy of the letter you are requesting and for correspondence during the letter writing process we require letter requestors to be enrolled in our Patient Ally Portal. *

Please enroll me in Patient Ally if I am not already enrolled.

Response requested? (see our privacy policy: https://johnnausmdpa.com/privacy-policy/) *

Please choose the purpose of letter that best matches your needs. *

FMLA or Short term disability
Long term disability
OTHER

If you were absent from work due to illness please list the Date / Time you first left work.

Date

Time

Please list the number of (days) you intend to need or have taken off of work in reference to this letter.

Please list the Date / Time you plan to return to work.( disability end date)

Date

Time

Do you want us to include your diagnosis in the letter? *

YES
NO

Intended Recipient (copy) *

Requested content of letter (symptoms that limit work / reasons for requested letter). Please be as detailed as possible about what you are requesting and what you would like the letter to say.

If you are requesting a return to work letter please include any special accommodations you feel are needed to return to work. (These may not be honored by your employer)

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