Short-Term Disability Paperwork Policy
Please read this policy before you request disability paperwork. When you submit your request online, you will be asked to agree to each part of it.
The Policy at a Glance
12 Weeks Maximum
Up to 6 weeks, plus one extension of up to 6 weeks.
Short-Term Only
We do not provide long-term disability evaluations.
$100 per Form
Paid before work begins. Medi-Cal members pay no fee.
Up to 10 Business Days
Once your request is complete.
Separate Evaluator
A disability evaluator, not your treating provider, completes forms.
- What’s covered
- Who qualifies
- Fees
- How it works
- The evaluator
- Your responsibilities
- Extensions
- Release authorization
1What This Policy Covers
Brainpower Wellness Institute completes short-term disability and leave paperwork, including:
- California State Disability Insurance (SDI) certification through EDD
- FMLA or CFRA leave certification for your employer
- Short-term disability claim forms from a private or employer insurer
- One extension and return-to-work forms for any of the above
Short-term only: 12 weeks maximum. Your first request covers up to 6 weeks. You may request one extension of up to 6 more weeks, for a total of 12 weeks. We do not certify disability beyond 12 weeks.
We do not provide long-term disability evaluations. Brainpower Wellness Institute does not conduct long-term disability evaluations or complete long-term disability paperwork. If your insurer requires one, you will need to arrange it with an outside evaluator.
Who completes your forms. Disability evaluations and paperwork are handled by our disability evaluator, a provider separate from your treating provider. Your treating provider continues your regular care but does not complete disability forms.
2Who Qualifies
We complete disability paperwork only for established patients in active treatment. All of the following must be true:
- You have completed your intake evaluation and at least one follow-up visit. We do not complete forms at the first visit.
- You were seen by your treating provider within the last 30 days.
- You are attending scheduled appointments and following your treatment plan.
- Your record documents the condition and symptoms the form asks about.
The disability evaluator decides whether completing a form is clinically appropriate. If you do not yet qualify, we will tell you what is needed, usually a scheduled visit.
3Fees
The fee is $100 per form. Each agency, insurer, or employer form counts separately, even for the same leave.
Medi-Cal members pay no fee. If you have Medi-Cal, including a Medi-Cal managed care plan, there is no charge for any disability, extension, or return-to-work form. The fees below apply to all other patients.
| Request | Fee |
|---|---|
| SDI certification (EDD) | $100 |
| Private or employer disability insurer form | $100 |
| SDI plus a private disability insurer | $200 (two forms) |
| FMLA or CFRA certification for your employer | $100 |
| Extension (one allowed) or return-to-work form | $100 |
| Correction of an error we made | No charge |
- Payment is due when you submit your request. Work begins only after payment is received.
- This fee is not billed to your health insurance. It does not count toward your copay or deductible.
- Refunds: you receive a full refund if the disability evaluator declines to complete the form. Once the form is completed and signed, the fee is non-refundable, whatever the outcome of your claim.
- The fee pays for the disability evaluator’s time to evaluate you, review your record, and complete the form. It is not payment for a particular result.
4How It Works and How Long It Takes
Paperwork may take up to 10 business days to complete after we have everything in steps 1 to 3. Incomplete requests do not start the clock.
- Complete the online disability request form and agree to this policy, with payment. Medi-Cal members pay no fee.
- Give us the paperwork, with your own section already filled out.
- For SDI: file your claim first through EDD’s SDI Online, then give us your form receipt number.
- For insurers and employers: give us the form and where to send it.
- Sign the release authorization included with the request form. We cannot release any information without it.
- Our office checks eligibility and completeness. If anything is missing, we contact you within 2 business days.
- You complete a disability evaluation with the disability evaluator, who reviews your record, including your treating provider’s notes, and completes the form.
- We send the form directly to the agency, insurer, or employer and post a copy to your patient portal.
Deadlines: submit your request at least 10 business days before any insurer or employer deadline. We cannot guarantee rush requests.
Status checks: please wait 10 business days before asking about status. Message us through the patient portal or call your office.
5What the Disability Evaluator Can and Cannot Do
The disability evaluator completes forms honestly, based on their clinical judgment and what is documented in your record. Completing a form does not mean your claim will be approved.
- Describe your diagnosis, symptoms, and how they affect your ability to work
- Certify up to 6 weeks, plus one extension of up to 6 weeks
- Estimate a start date and return-to-work date, based on their evaluation and your record
- Recommend work restrictions the record supports
- Respond to insurer questions you have authorized
- Guarantee approval, benefit amounts, or the length of benefits. The agency or insurer decides.
- Certify more than 12 weeks in total, or more than one extension
- Backdate a start date to a period that was not evaluated or documented
- Change diagnoses, findings, or dates to fit a claim
- Certify conditions treated outside our practice, such as a physical injury
- Certify disability when the record does not support it
If the disability evaluator does not believe you are unable to work, they will discuss this with you directly. You may seek a second opinion.
6Your Responsibilities
Your claim moves faster when you do your part completely and on time.
- Fill out your own sections of every form before you submit it.
- Give accurate details: employer, insurer, claim or receipt number, and last day worked.
- Keep your appointments with your treating provider and the disability evaluator. Missed visits may prevent an extension.
- Tell us right away about changes: returning to work, a new job, or a change in symptoms.
- Track your own deadlines with your insurer and employer.
- Answer insurer or EDD requests sent to you. Appeals of a denied claim are between you and the insurer; any extra forms for an appeal follow the same fee rules.
7Extensions, Return to Work, and Other Requests
Extensions: one extension of up to 6 weeks is allowed, for a maximum of 12 weeks in total. Request it at least 10 business days before your current end date. It requires a follow-up evaluation with the disability evaluator and a visit with your treating provider within the last 30 days. The extension form is $100 (no fee for Medi-Cal members).
Return to work: tell us your expected return date as soon as you know it. A return-to-work or release form required by your employer or insurer is $100 (no fee for Medi-Cal members).
Not provided: long-term disability evaluations or paperwork, and any disability beyond 12 weeks.
Not covered by this policy. These need a separate request, may be declined, and any fee is quoted in advance:
- Letters or narrative reports for attorneys
- Depositions or court testimony
- Workers’ compensation evaluations
- Social Security disability (SSDI/SSI) medical source statements
- Fitness-for-duty or independent medical evaluations
Copies of your medical records follow our separate records request process.
8About the Release Authorization
Before we can send any forms, you will sign an authorization that allows us to release information to the agencies, insurers, and employers you list.
- What is released
- Diagnosis, dates of treatment, symptoms and functional limitations, treatment plan, medications, prognosis, work restrictions, and expected return-to-work date. Only what is needed to complete your forms. Psychotherapy notes are never included.
- Sensitive information
- Substance use treatment information and HIV test results are released only if you specifically choose to allow it.
- How long it lasts
- While you are a client of Brainpower Wellness Institute, unless you revoke it sooner in writing.
- Your rights
- You may revoke it in writing at any time, except for information already released. Your treatment does not depend on signing it, and you are entitled to a copy.
- Redisclosure
- Information released to a recipient may be shared again by that recipient and may no longer be protected by federal privacy law.
Questions About This Policy?
Message us through the patient portal, call (714) 712-0711, or email brainpower@bpwimh.com.
This policy applies to short-term disability and leave paperwork at all Brainpower Wellness Institute locations.