Please submit your FMLA / Disability request

Prior to completing the form, please have a copy of your medical certification form in PDF format ready.
Please note, your paperwork will not be processed until 30 days prior to your scheduled surgery date.

 

FMLA Leave Limitations:

Office Work – Maximum of 2 weeks off
Labor Intensive Job – Maximum of 4 weeks off
If submitting for companion – Week of stay only

 

Need help or have any questions?

Reach out to your coordinator directly or give us a call at 855-BLOSSOM.

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