forms library

medical release forms  

The following forms are used to authorize the release of medical and other information for absences under the program. 

All of these forms allow Reed Group to communicate directly with your doctor(s) regarding your absence. Medical records or treatment records can be requested from your doctors on your behalf so Reed Group can review the documentation and discuss the illness or injury with your doctor or your family member’s doctor, as appropriate. 

  • Short-term disability authorization for release of medical and other information form. You need to complete this form when you’re absent for more than five consecutive workdays because of your own illness or injury (and you’re not covered under Kaiser Permanente). You may also be required to complete the FMLA Medical Release (Personal) form under certain situations, such as when your STD benefits end but you continue to take time off that is covered under FMLA. If you’re incapacitated, a legal guardian should complete the form.
  • FMLA medical release (personal) form. You need to complete this form when you’re requesting an FMLA-protected absence for your disability. If you are incapacitated, a legal guardian should complete the form.
  • FMLA medical release (family member) form. You need to submit this form when you’re requesting time off under FMLA to care for a seriously ill family member. The family member for whom you’re providing care should complete the form. If he or she is a minor, a parent or legal guardian should complete the form. If he or she is incapacitated, a legal guardian should complete the form.
  • Long-term disability authorization for release of medical and other information form. If you’re disabled for a long period of time and you’re applying for benefits from the Long-Term Disability Plan, you need to complete this form. It authorizes the release of information to help certify your disability. If you’re incapacitated, a legal guardian should complete the form. 

kaiser medical release forms

If you're a Kaiser member, you need to complete a form when you're absent for more than five consecutive workdays because of your own illness or injury. You may also be required to complete the FMLA Medical Release (Personal) form under certain situations, such as when your STD benefits end but you continue to take time off that is covered under FMLA. If you're incapacitated, a legal guardian should complete the form.

forms for medical certification and documentation

for short-term and long-term disability cases

  • Attending physician’s statement form. Your doctor(s) needs to complete this form in order to provide medical certification and documentation of your disability, as required under the provisions of the Chevron Short-Term Disability (STD) and Long-Term Disability (LTD) Plans. If you are under the care of more than one doctor or caregiver, each of them must complete and submit this form. This form should be used if the cause or nature of your medical condition and related disability is due to a physical sickness or injury.
  • Behavioral health attending physician's statement form. Your doctor(s) need to complete this form in order to provide medical certification and documentation of your disability, as required under the provisions of the Chevron Short-Term Disability (STD) and Long-Term Disability (LTD) Plans. If you are under the care of more than one doctor or caregiver, each of them must complete and submit this form. This form should be used if the nature of your medical condition and the related disability is due to a mental health or substance abuse problem.

for FMLA and related state leave laws, including california paid family leave (PFL)

If you are taking time off for a reason that's covered under the Family and Medical Leave Act of 1993 (FMLA) or a related state leave law, you need to submit the appropriate form to provide the necessary certification and documentation in support of your absence. Most of them require a licensed physician to complete a section of the form. 

chevron family leave and personal leave without pay forms

family and medical leave act of 1993 (FMLA) forms