Pennsylvania 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.  MediCopy will send you an invoice to be paid before the form(s) is completed. 

Individually submitted forms will be charged at $30. If you submit multiple forms at the same time, the first form will be charged at $30 and each additional form will be charged at $15. The form will not be completed until the invoice is paid. To quickly receive your invoice, please include your email address with your submitted form(s). 

4.  Once payment is received, MediCopy will complete your form(s) within three business days.

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.