[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-275420-105":53,"doc-detail-275420-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","fmla-intake-form-15-calendar-days-processing","FMLA Intake Form - 15 Calendar Days Processing","","FMLA intake and request form used to collect required patient, caregiver, and employer information for leave approval. It instructs reviewers that incomplete submissions delay processing and that requests can take up to 15 calendar days. The form captures patient identity, condition details, clinician authorization, work status and history, and selects the FMLA type: intermittent, continuous, or other (including reduced daily work hours).",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/fmla-intake-form-15-calendar-days-processing/275420/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/fmla-intake-form-15-calendar-days-processing/275420.png","ImageObject",442,249,{"name":88,"@type":89},"Fez","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-15",true,{"@type":98,"interactionType":99,"userInteractionCount":8},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"How long does it take to process an FMLA form request?","Question",{"text":108,"@type":109},"Processing may take up to 15 calendar days. Incomplete forms will delay processing time.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information is required to submit the form?",{"text":113,"@type":109},"The form requires complete patient information, caregiver details if applicable, condition details, clinician authorization information, and employer work status/history details.",{"name":115,"@type":106,"acceptedAnswer":116},"Which FMLA types can be requested on this form?",{"text":117,"@type":109},"You can request intermittent leave, continuous leave, or other leave. The form instructs completing the relevant sections (typically #5, #6, or #7) for the chosen type.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},275420,1790119347,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":8,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},2336478940794,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","PLEASE REVIEW DIRECTIONS ON THE OTHER SIDE OF THIS FORM. INCOMPLETE FORMS WILL DELAY PROCESSING TIME. PLEASE INFORM THE PATIENT FMLA FORM PROCESS WILL TAKE UP TO 15 CALENDAR DAYS.  \nKP USE ONLY  \n\n| KP Use Only: Your requested FMLA dates may not be approved exactly as requested. The FMLA Department follows federal guidelines when reviewing and approving all requests. |  |\n| --- | --- |\n| | Employee Complete all except \\#2  Complete ROI for caregiver request\u003Cbr>Family member/Caregiver complete all sections.\u003Cbr>Executive Staff only |\n\n\n|  | Patient Information | Date Submitted by patient: | Date of Birth (mm/dd/yy): | Patient Health Record \\#: |\n| --- | --- | --- | --- | --- |\n| 1 |  |  |  |  |\n|  | Must be filled out completely | Patient Full Name: |  | Contact Telephone \\#:\u003Cbr>Best Time to Call: |\n\nYes  No-Is this form for the patient’s employer? If yes, skip \\#2 and complete \\#3 thru 7 (if applicable)  \n\n|  | Caregiver/Family Member\u003Cbr>Leave blank if request is for patient time off | Name of Caregiver/Family Member who will be providing the care: | Contact Telephone \\#:\u003Cbr>Best Time to Call: |\n| --- | --- | --- | --- |\n| 2 |  |  |  |\n|  |  |  |  |\n|  |  | Relationship to Patient: |  |\n\n\n|  | Patient’s Condition\u003Cbr>Must be filled out completely | Name of treating Clinician/MD Authorizing Time Loss: | Medical Condition: |\n| --- | --- | --- | --- |\n| 3 |  |  |  |\n|  |  | Initial date of Condition: |  |\n|  |  |  |  |\n\nFront Desk/Nursing Staff: ROI form also needs to be completed by the patient ifFMLA is for the caregiver.  \n\n|  |  | Employer Name (company that you work for): | Employee’s Job Title: |\n| --- | --- | --- | --- |\n|  | Work Status |  |  |\n|  | History\u003Cbr>Must be filled |  |  |\n| 4 |  |  | Job Functions: |\n|  | out completely |  |  |\n|  |  |  | Work Schedule: |\n|  | Which TYPE of FMLA? MUST complete either \\#5, \\#6, or \\#7 or any combination of the 3 (if applicable). |  |  |\n|  | Intermittent Leave\u003Cbr>(2 treatment visits needed in the past 12 months to qualify: inperson, tele, video) | ESTIMATE THE NUMBER OF DAYS YOU MAY NEED FOR THIS REQUEST:\u003Cbr>Total \\# of work absences per month    Not Applicable\u003Cbr>Start Date (mm/dd/yy):   *Please note that 6 months is the longest that\u003Cbr>Duration  3 months  6 months intermittent FMLA will be approved for. |  |\n| 5 |  |  |  |\n|  |  |  |  |\n\n\n|  | Continuous Leave | Start Date:  \u003Cbr>Return to work date:\u003Cbr> Not Applicable | Notes/Comments: |\n| --- | --- | --- | --- |\n| 6 |  |  |  |\n|  |  |  |  |\n\n\n|  | Other Leave |  |  Reduce Daily Work Hours\u003Cbr>Start Date:    Not Applicable\u003Cbr>Returning to regular work hours:  \u003Cbr>\\# hours per day:   \\# days per week:   |\n| --- | --- | --- | --- |\n| 7 |  |  |  |\n|  |  |  |  |\n\nDIRECTIONS—Is this request for treatment by a specialist/surgeon?  \nIf YES, please have specialist/surgeon complete your form.  \n*Please note that FMLA forms can take up to 15 calendar days to process.*  \n\n| Patient Information | Please fill in ALL patient information. |\n| --- | --- |\n\n\n| Caregiver/ Family Member Request | If you are completing this form to assist in care of the patient and you are the caregiver, please include your name, your relationship to the patient (i.e. , parent, spouse, child), your telephone number along with the best time of day to call. *The patient receiving the care will also need to complete a Release of Information Form (ROI) for the caregiver. * |\n| --- | --- |\n\n\n| Patient’s\u003Cbr>Condition | Please provide the medical condition related to this request and the date the condition or injury occurred for the first time. If the exact date cannot be remembered, give an estimated month and year. Also, provide the name of your treating clinician/doctor. |\n| --- | --- |\n\n\n| Work Status\u003Cbr>History | Please provide the name of the company that the patient works for. Also, include job title, job functions and work schedule.\u003Cbr>If the FMLA is for you (patient) to take time off due to your own condition, please list you employer\u003Cbr>If the FMLA is for your ca","cbCaitx2WFAW2g1z","https://ap.wps.com/l/cbCaitx2WFAW2g1z","pdf",143447,"English","# Patient Information\n## Caregiver/Family Member Request\n## Patient’s Condition\n## Employer Name and Work Status History\n## Type of FMLA Request\n### Intermittent Leave\n### Continuous Leave\n### Other Leave\n## Directions and Comments","[{\"question\":\"How long does it take to process an FMLA form request?\",\"answer\":\"Processing may take up to 15 calendar days. Incomplete forms will delay processing time.\"},{\"question\":\"What information is required to submit the form?\",\"answer\":\"The form requires complete patient information, caregiver details if applicable, condition details, clinician authorization information, and employer work status/history details.\"},{\"question\":\"Which FMLA types can be requested on this form?\",\"answer\":\"You can request intermittent leave, continuous leave, or other leave. The form instructs completing the relevant sections (typically #5, #6, or #7) for the chosen type.\"}]","FMLA Intake Form - 15 Calendar Days Processing | PDF",1789487328]