For Patients & Families

Information for Patients

How to Process a Disability or FMLA Claim

If you are applying for a leave of absence from your place of work either because of your medical condition or to assist a family member with their medical condition, you will need to complete paperwork for a Short or Long Term Disability claim from an insurance provider, or for the Family Medical Leave Act (FMLA). Your request will be processed by a Disability/FMLA Coordinator at Dana-Farber in the Health Information Services department (HIS).

For Disability, HIS requires:

• A copy of all Disability paperwork from your insurance provider
  • Complete any claimant portions of the paperwork – sign and date as forms instruct
  • Include due date when submitting paperwork to avoid delays in processing
   
• A signed Authorization to Release Protected Health Information (PHI), available in English and Spanish
  • Detailed instructions are included in the PDF file with the authorization form
  • Completed Disability paperwork can only be submitted to the requesting insurance company. An authorization with insurance company contact information is required to release any disability-related information. To have a copy sent to an employer, a separate authorization is required.
    
    Authorization forms from your insurance provider/employer may also be acceptable.
   

For FMLA, HIS requires:

• A copy of all FMLA paperwork from your employer
  • Complete any patient portions of the paperwork – sign and date as forms instruct
  • Include due date when submitting paperwork to avoid delays in processing
  • Please include a note to indicate whether you are seeking continuous or intermittent leave, amount of leave requested, and any specific start and end dates
  • A signed Authorization to Release Protected Health Information (PHI), available in English and Spanish
  • Detailed instructions are included in the PDF file with the authorization form
  • Completed FMLA paperwork will be mailed to the patient address on file for the patient to submit unless the patient completes an authorization designating an employer or other third party as the recipient of PHI.
    
    Authorization forms from your insurance provider/employer may also be acceptable.
   

Send all paperwork by mail, fax, or email to Health Information Services:

DFCI HIS Correspondence
27 Drydock Ave., 4th Floor
Boston, MA 02210
FAX attn HIS: 617-394-2647
Email: correspondence_roi@dfci.harvard.edu

HIS will coordinate with your physician to provide your insurer/employer with the information necessary to process your claim/leave request.

If you have any questions or would like an update on the status of your request, please call the Disability/FMLA Coordinators at 617-632-2955 (Select OPTION 1 after the prompt). Please allow 5 to 7 business days for your request to be processed.

Please note: Requests for Medical Records are processed separately. HIS will forward requests for medical records to the appropriate department. Get complete Medical Records information.

For the status of your medical records request, please call 617-481-0541.