Form Fee Menu

Level 1 $20 or waived as courtesy if brought to visit

• State and City wellness forms

• Student Nursing

• Authorization to Return to work after COVID-19       

• Handicap application

• Child Care Clearance

• Preemployment or school sports exam

Level 2 $30 or waived as courtesy if brought to visit

• Attending Physician Statement

• COVID "work from home" request

• Any workplace accommodations or limits letter

• Activities of Daily Living verification or limitations; letter or form

• School bus driver clearance

• Surgical clearance letters or forms

• Foster parent clearance

• Any other government forms

• All other forms or letters

 Level 3 $40 and separate from any required visit co-pay

• FMLA

• Disability forms

• LTD or Life insurance forms or questionnaires

With the understanding that no Functional Capacity Evaluation or disability ratings portion of any form will be completed

Work or school excuses and verification of status requests, in our format and on our own letterhead, are free of charge.

All forms should be brought with you to your visit.  Montgomery Family Medicine is not responsible for providing any forms.  Forms outside a visit must be taken to the front receptionist for intake.