SFDC: 500Kh00000Yj6r4IAB E105 vs 10.
18 10542212
Dear Treating Provider,
Your patient has requested an absence from work, and disability benefits related to their own illness or injury. In order
to accurately assess your patient’s functional status and eligibility for disability benefits, the following information is
required. In completing this form, we ask that you:
[ ] Provide answers and best estimates based on your medical knowledge, experience, and assessment of the patient.
[ ] Provide relevant ICD 10 and CPT code to help expedite your patient’s absence case decision.
[ ] Provide information as specific as possible. Terms such as “unable to determine,” or “as needed” may not be
sufficient to approve a request for FMLA, and disability leave and paid benefits.
[ ] Along with the completed form, please provide Office/Progress Notes or other relevant Medical Records
If a covered entity uses language such as the following, any receipt of genetic information in response to the
request for medical information will be deemed inadvertent: “The Genetic Information Nondiscrimination Act
of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring
genetic information of an individual or family member of the individual, except as specifically allowed by this
law. To comply with this law, we are asking that you not provide any genetic information when responding to
this request for medical information. ‘Genetic information' as defined by GINA, includes an individual's family
medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an
individual's family member sought or received genetic services, and genetic information of a fetus carried by
an individual or an individual's family member or an embryo lawfully held by an individual or family member
receiving assistive reproductive services.
Return the completed form and any other medical records by:
Fax #: 1-855-579-1799, or
Email: amazondls@amazon.com.
Please upload your document via the Self-Service Portal, e-mail to amazondls@amazon.com or fax to 1-855-579-1799
Page 1 of 2
SFDC: 500Kh00000Yj6r4IAB E105 vs 10.18 10542212
Behavioral Health Physician Statement
This form needs to be completed by treating provider or treating provider
office only Fax to 1-855-579-1799 or by email to amazondls@amazon.com
Patient Name: Ariana Sandoval Patient Date of Birth: June 12, 2001
Patient Job Title: Area Manager Case Number: 10542212
Requested Leave Start March 29, 2025 Requested Return to September 9, 2025
Date: Work:
Physical Demand: Regular Full Time
1. Diagnostic Information
Primary Diagnosis: _________________________________________ ICD-10: __________ Date of Onset: ___/___/____
Secondary Diagnosis impacting work: __________________________ ICD-10: __________
Is the patient’s primary condition due to injury or illness arising out of the patient’s employment? [ ] No [ ] Yes
2. Treatment Information
• Office visits: Most recent visit date: ____/____/_____ Next visit: ____/____/_____
• If Hospitalized, Admitted on: _____/_____/_____ Discharged on: _____/_____/_____
• If Patient referred to specialist, Providers Name_______________________ Specialty _________Phone#__________
3. Clinical and Functional Assessment
Do you consider your patient to be totally impaired from working? [ ] No [ ] Yes
If yes, as of what date? ____/____/____, with an actual / expected return to work date of ___/____/____
If yes, as supported by the following rationale based on patients most recent evaluation on ___/____/____ (citing
Mental Status Exam findings, patient’s functional impairments, your assessment).
Within Normal
Date of Evaluation: Limits Impaired As Evidenced By:
A. General/Behavior Observations [] []
B. Language/Thought functioning [] []
C. Emotional functioning (Mood/
Affect)
[] []
D. Cognitive functioning [] []
1. Focus/Attention/Memory [] []
2. Insight/Judgement/ Problem
Solving/Decision making
[] []
3. Multitasking [] []
Please upload your document via the Self-Service Portal, e-mail to amazondls@amazon.com or fax to 1-855-579-1799
Page 2 of 2
4. Return to Work Planning
What is the estimated date of the patient’s release to modified duty ___/____/____and to full duty ___/____/____
Are there any temporary work restrictions and/or accommodations which would allow your patient to return to work?
[ ] No [ ] Yes, If Yes please specify by providing objective quantification e.g. work for 6 hr/day for 4 weeks.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Provider’s Name and Credentials (MD, DO, etc.) Specialty Date:
Signature Phone: Fax:
