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New Jersey Rothman Steps For Form Completion

1. Submit an authorization/intake form online, or download a PDF version to be combined and submitted with your Disability or FMLA form. 

           Intake Authorization Form (English) or Intake Authorization Form (Spanish)

2. Submit your Disability or FMLA form(s) in PDF format online here

Please submit blank forms as scanned PDF documents only (preferably as one combined document). Photos or pictures taken of blank forms cannot be accepted. 

If you do not use the online submission you may fax the form to 833-417-8313. Be sure to include a copy of the completed intake authorization form in step 1 or a cover sheet that includes the patient's name, date of birth, and doctor's name. 

PLEASE NOTE: Long-term and short-term disability forms require an authorization form in order to be completed. We accept all valid HIPAA authorization forms and have provided an Intake Authorization Form for your use in step 1 at the top of the page. 

Once we receive your form(s), here is what to expect:

3.  Non-disability forms are $30 for the first form and $15 for each additional form turned in at the same time. Once received, MediCopy will send an invoice. Upon invoice payment, MediCopy will complete the form(s) within three business days and send to the requesting party.

4.  Temporary disability forms will be completed and sent to the requesting party at no cost to the patient within three days of receipt.

5.  Upon completion, forms will be sent to the designated requesting party.

You may also request a copy of the completed form to be emailed to you as well. Please note on your form(s) or the intake form that you would like a copy and provide a valid email address.