For Patients & Families

Information for Patients

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 (HIS) department.

For disability claims, please follow these steps:

• Send us copies of all disability paperwork from your insurance provider. Fill out any claimant portions of the paperwork. Sign and date forms as instructed.
• Fill out our Request Form and send it to us, adding your specific disability dates, along with any special instructions.
• Complete and sign our Authorization to Release Protected Health Information (PHI) form, available in English and Spanish. Find detailed instructions in the PDF.
• Be sure to include contact information for your requesting insurance company so that we can release your disability-related information. To have a copy sent to your employer, a separate authorization is required.
  
  Authorization forms from your insurance provider/employer are acceptable.

For FMLA claims, please follow these steps:

• Send us copies of all FMLA paperwork from your employer. Fill out any claimant portions of the paperwork. Sign and date forms as instructed.
• Fill out our Request Form and send it to us, adding your specific disability dates, along with any special instructions.
• Complete and sign our Authorization to Release Protected Health Information (PHI) form, available in English and Spanish. Find detailed instructions in the PDF.
  
  Authorization forms from your insurance provider/employer are acceptable.

You can provide us your paperwork in person or send by mail, fax, or email:

Mail: DFCI Health Information Services
450 Brookline Ave., OS229
Boston, MA 02215
FAX: Attn HIS: 617-394-2647
Email: correspondence_roi@dfci.harvard.edu
In person:

• Boston/Yawkey: Health Information Services on the second floor of the Yawkey Center for Cancer Care (450 Brookline Ave.), next to Central Registration
• Chestnut Hill: Health Information Services on the 3rd floor of Dana-Farber Cancer Institute - Chestnut Hill (300 Boylston St., Newton) in Central Registration
• Regional Sites: At the checkout desk, or ask for a Health Information Services/Medical Records team member

We 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 our Disability/FMLA Coordinators at 617-632-2955 (select OPTION 2 after the prompt). Each request can take a minimum of 14 days to process.

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 617-632-2955 (select OPTION 1 after the prompt).

Commonly requested forms

• Authorization to Release Protected Health Information (PHI), in English and Spanish
• Request Form for Disability/FMLA/PFML
• Next Steps Information Sheet for Disability/FMLA/PFML

What to expect once submitted

After we receive all of your required documents, each request takes a minimum of 14 days to process. Once completed, we will send you an electronic copy of your forms through Patient Gateway, or to the authorized recipient. If you do not have a Patient Gateway account or a signed authorization, the completed documentation will be sent via mail to the address on file with Dana-Farber.