December 19, 2017

Olivia Sapp
PO BOX 621
LEESBURG, GA 317630621

RE: Phoebe Putney Health Systems

Group No: 156262
Leave No: 389364
Dear Ms. Sapp:
We are writing concerning your leave request and Disability claim with Standard Insurance Company (The
Standard), who has been retained by Phoebe Putney Health Systems to administer their leave program and
insure their disability program.
This letter is to notify you of our initial determination that you are eligible for leave under the leave laws
and/or policies outlined below. Additional information necessary for finalization of both your leave and your
Disability claim are explained below.

LEAVE INFORMATION
Our records indicate that you need Family/Medical Leave for your pregnancy or related conditions to begin
12/13/2017 and that you expect this leave to continue until approximately 02/07/2018. Your eligibility has
been reviewed and you are eligible to take a qualifying leave under the following leave laws and/or policies:
Family and Medical Leave Act - 10 Weeks starting availability
Personal Medical Leave

Please note, this letter confirms that you meet the eligibility requirements for the above leave laws and/or
policies. However, a final decision regarding approval or denial of your leave has not yet been made. You
and your employer will be notified of our decision in writing at a later date.
If approved, your requested leave will be counted against your entitlement under the applicable leave laws
and/or policies listed above.

WHAT YOU NEED TO DO

The following information will help guide you through the leave process. You may want to keep it for your
records.

1. Submit the Health Care Provider Certification Form

In order for The Standard to complete a full review to determine if your request for absence qualifies
under applicable leave laws and/or policies, we will need the enclosed medical form completed and

Standard Insurance Company

P.O. Box 3877
Portland, OR 97208
Olivia Sapp Page 2 December 19, 2017

signed by your health care provider and returned to us by 01/06/2018.

You or the medical provider’s office can fax, email or mail the completed, signed Certification form to
us at:
Standard Insurance Company
PO Box 3877
Portland, OR 97208
Fax: 1-866-751-5174 Email: absence@standard.com
It is your responsibility to make sure the information requested above is submitted on time.
If a completed and signed form is not received by 01/06/2018, or does not support your request for
leave, your request will not be approved and your time away from work will not be job protected and
may impact your employment status. If you are unable to return the medical form to The Standard by
the due date, please contact us to tell us why you are unable to return it timely, and when you can
return the Certification.
2. Notify The Standard if anything changes
Please notify us if the circumstances of your leave change including additional expected absence dates
(including intermittent full or partial days), postponement or cancellation of your planned absence(s).
If you are able to return to work earlier than 02/08/2018, please notify us at least two workdays prior
to the date you intend to report for work so that we can coordinate a smooth transition of your job
duties.
3. Notify Phoebe Putney Health Systems
To ensure that your insurance coverage is in order and benefits are maintained, contact your
supervisor/manager periodically regarding your status. Also, it is important that your contact
information be kept current while you are out on leave.

Please also ensure that you have read Phoebe Putney Health Systems leave of Absence Policy, which
can be accessed by logging onto Phoebe Putney Health Systems Employee Benefits Website. You can
access the website by going to:
https://mybensite.com/phoebe
Log in with the following User ID and Password:
User ID: phoebe
Password: benefits
From the website, select the LOA tab, located in upper section of screen. Informational options are
located on left hand side of screen.

YOUR RIGHTS UNDER FMLA

If your leave is covered by FMLA, you have a right to up to 12 weeks of unpaid, job-protected leave in a
12-month period. If your leave is covered by other government-mandated laws, you have a right to the
amount of leave allowed by those applicable laws. The starting entitlement shown above is your current
entitlement; it reflects the amount of time allowed by law and takes into account any time you may have
already used in the current period.
To track leave entitlement, the 12-month period is calculated as:
a "rolling" 12-month period measured backward from the date of any government-mandated leave

Standard Insurance Company

P.O. Box 3877
Portland, OR 97208
Olivia Sapp Page 3 December 19, 2017

usage

Enclosed for your review is information containing your rights and obligations under federal and/or state
family/medical leave laws.

RECERTIFICATION
While on leave you may be required to recertify your leave. When recertification is needed, we will send you
an additional form for your health care provider to complete and return to our office to certify additional time
away from work.

WHAT HAPPENS TO YOUR PAY AND BENEFITS

Use of Paid Time
If your leave is approved, you will be required to use your available PHO and EIB hours/ during your absence
If you exhaust your PHO and/or EIB hours, your leave becomes unpaid.
If you receive PHO and/or EIB hours, this time will also be considered protected FMLA or
government-mandated leave and will be counted against your leave entitlement under these policies/laws.
During your absence from work, you can access your pay information from home through the
APILaborworkx® self-service portal. To access APILaborworkx® from home, you can either go directly to
https://myphoebepay.phoebeputney.net/LaborWorkx/ or you can access it from the Phoebe Putney home
page at www.phoebeputney.com. Click on the Employee Connect link in the top banner, then scroll down to
the Employee Self Service link and click Log In.
Use the login credentials as you normally would to access APILaborWorkx® from work. For Username and
Password assistance, please contact the Phoebe Putney Help Desk at 312-6333.

Health Insurance
If your leave becomes unpaid, your missed benefit premium deductions will be collected within an arrears
account. These missed premiums will be taken from your first paycheck when you return to work. please
contact the Benefits Department at 229-312-4388 to make payment arrangements upon your return to work.
If your leave is approved under FMLA, your health benefits must be maintained during any period of leave
under the same conditions as if you continued to work. If you do not return to work at the end of an FMLA
leave, you may be required to repay any health insurance premiums which were paid on your behalf by
Phoebe Putney Health Systems during your leave.

WHAT HAPPENS TO YOUR JOB

Reinstatement Rights – FMLA
Upon your return from approved leave, you must be reinstated to the same or an equivalent job with the same
pay, benefits, and terms and conditions of employment as prior to your leave. NOTE: If your leave extends
beyond the end of your FMLA or other job-protected leave entitlement, you will not have this right to
reinstatement. Some of the leave policies described above may not include job protection.
Non-FMLA Leaves
Non-FMLA leaves, such as a Medical or Personal Leave of Absence offered through your employer, are not
subject to FMLA laws and regulations. These leaves typically do not guarantee job reinstatement.
If you have questions regarding your job status under a non-FMLA leave please refer to your Employee
Handbook or contact your HR Representative.

Standard Insurance Company

P.O. Box 3877
Portland, OR 97208
Olivia Sapp Page 4 December 19, 2017

SUMMARY OF ENCLOSED DOCUMENTATION

Enclosed for your review with this letter is information regarding:
Your rights and obligations under federal and/or state family/medical leave laws

The form(s) to be completed and returned

Phoebe Putney Health Systems’s Employee Assistance Program

Health Advocacy Services

DISABILITY BENEFIT INFORMATION

INFORMATION NEEDED TO FINALIZE CLAIM
The following information is necessary to finalize your Disability claim:
Attending Physician's Statement (We have faxed this document to your treating physician for
completion. This statement will be utilized for both your leave of absence and your Disability claim.
We have enclosed a copy of this form for your information.)
Authorization To Obtain And Release Information (Please sign, date and return it by mail in the
postage-paid envelope, or fax it to 1-866-751-5174.)
If you need additional forms, you may call our office at the number below. If there is a reason why you are
unable to provide the requested information, please let us know.
Please note we have included a copy of Claim Form Fraud Notices for your review. As soon as all necessary
information is received, we will begin a full review of your Disability claim. You will be advised when a
decision is made.
CONCLUSION
FOR MORE INFORMATION
We hope this letter helps you understand the steps necessary for the finalization of both your leave and
Disability claim. If you have questions or need to make changes in your expected leave dates, you may call
our office at the number below. Please have your company name and your leave number on hand (as listed
above). We will be happy to assist you.
Sincerely,
Absence Management Service Center
1-866-756-8116

Standard Insurance Company

P.O. Box 3877
Portland, OR 97208
 A

EMPLOYEE RIGHTS
UNDER THE FAMILY AND MEDICAL LEAVE ACT
THE UNITED STATES DEPARTMENT OF LABOR WAGE AND HOUR DIVISION

LEAVE Eligible employees who work for a covered employer can take up to 12 weeks of unpaid, job-protected leave in a 12-month period
ENTITLEMENTS for the following reasons:

x The birth of a child or placement of a child for adoption or foster care;

x To bond with a child (leave must be taken within 1 year of the child’s birth or placement);
x To care for the employee’s spouse, child, or parent who has a qualifying serious health condition;
x For the employee’s own qualifying serious health condition that makes the employee unable to perform the employee’s job;
x For qualifying exigencies related to the foreign deployment of a military member who is the employee’s spouse,
child, or parent.
An eligible employee who is a covered servicemember’s spouse, child, parent, or next of kin may also take up to 26 weeks
of FMLA leave in a single 12-month period to care for the servicemember with a serious injury or illness.

An employee does not need to use leave in one block. When it is medically necessary or otherwise permitted, employees
may take leave intermittently or on a reduced schedule.

Employees may choose, or an employer may require, use of accrued paid leave while taking FMLA leave. If an employee
substitutes accrued paid leave for FMLA leave, the employee must comply with the employer’s normal paid leave policies.

BENEFITS & While employees are on FMLA leave, employers must continue health insurance coverage as if the employees were not on leave.
PROTECTIONS Upon return from FMLA leave, most employees must be restored to the same job or one nearly identical to it with
HTXLYDOHQWSD\EHQHÀWVDQGRWKHUHPSOR\PHQWWHUPVDQGFRQGLWLRQV

An employer may not interfere with an individual’s FMLA rights or retaliate against someone for using or trying to use FMLA leave,
opposing any practice made unlawful by the FMLA, or being involved in any proceeding under or related to the FMLA.

ELIGIBILITY An employee who works for a covered employer must meet three criteria in order to be eligible for FMLA leave. The employee must:
REQUIREMENTS x Have worked for the employer for at least 12 months;
x Have at least 1,250 hours of service in the 12 months before taking leave;* and
x Work at a location where the employer has at least 50 employees within 75 miles of the employee’s worksite.
6SHFLDO´KRXUVRIVHUYLFHµUHTXLUHPHQWVDSSO\WRDLUOLQHÁLJKWFUHZHPSOR\HHV

REQUESTING Generally, employees must give 30-days’ advance notice of the need for FMLA leave. If it is not possible to give 30-days’ notice,
an employee must notify the employer as soon as possible and, generally, follow the employer’s usual procedures.
LEAVE
Employees do not have to share a medical diagnosis, but must provide enough information to the employer so it can determine
LIWKHOHDYHTXDOLÀHVIRU)0/$SURWHFWLRQ6XIÀFLHQWLQIRUPDWLRQFRXOGLQFOXGHLQIRUPLQJDQHPSOR\HUWKDWWKHHPSOR\HHLVRU
will be unable to perform his or her job functions, that a family member cannot perform daily activities, or that hospitalization or
continuing medical treatment is necessary. Employees must inform the employer if the need for leave is for a reason for which
)0/$OHDYHZDVSUHYLRXVO\WDNHQRUFHUWLÀHG

(PSOR\HUVFDQUHTXLUHDFHUWLÀFDWLRQRUSHULRGLFUHFHUWLÀFDWLRQVXSSRUWLQJWKHQHHGIRUOHDYH,IWKHHPSOR\HUGHWHUPLQHVWKDWWKH
FHUWLÀFDWLRQLVLQFRPSOHWHLWPXVWSURYLGHDZULWWHQQRWLFHLQGLFDWLQJZKDWDGGLWLRQDOLQIRUPDWLRQLVUHTXLUHG

EMPLOYER Once an employer becomes aware that an employee’s need for leave is for a reason that may qualify under the FMLA, the
RESPONSIBILITIES employer must notify the employee if he or she is eligible for FMLA leave and, if eligible, must also provide a notice of rights and
responsibilities under the FMLA. If the employee is not eligible, the employer must provide a reason for ineligibility.

Employers must notify its employees if leave will be designated as FMLA leave, and if so, how much leave will be designated as
FMLA leave.

ENFORCEMENT (PSOR\HHVPD\ÀOHDFRPSODLQWZLWKWKH86'HSDUWPHQWRI/DERU:DJHDQG+RXU'LYLVLRQRUPD\EULQJDSULYDWHODZVXLW
against an employer.

The FMLA does not affect any federal or state law prohibiting discrimination or supersede any state or local law or collective
bargaining agreement that provides greater family or medical leave rights.

For additional information or to file a complaint:

1-866-4-USWAGE
(1-866-487-9243) TTY: 1-877-889-5627

www.dol.gov/whd
U.S. Department of Labor Wage and Hour Division

WH1420 REV 04/16

 a
a
Standard
Standard Insurance
Insurance Company
Company
866.756.8116
866.756.8116 Tel Tel 866.751.5174
866.751.5174 Fax Fax Disability Claim/Family Medical Leave
PO Box
PO Box3877
3877Portland
Portland OR 97208
OR 97208 Attending Physician’s Statement

To Be Completed By Employee
Full Name: Leave# Employer/Company Name: Group Policy No.:
Olivia Sapp 389364
Federal law requires us to notify you that sections marked with * are required for purposes of completing your disability claim.

To Be Completed By The Attending Physician

The following information is needed to document the patient’s inability to work. The patient is responsible for obtaining a complete form without expense
to The Standard. Please complete this form and mail or fax it to The Standard using the contact information listed above.
A. Diagnosis ICDA Classification
1. Diagnosis
B. Symptoms *C. Height Weight B/P

A. Expected date of delivery B. Actual date of delivery

2. Pregnancy (if applicable) Vaginal C-section
A. Date you recommended the patient stop work B. When did symptoms appear or accident happen?
3. History and Treatment

*C. Has the patient ever had the same or similar condition? Yes No If yes, when?

*D. Is this condition related to the patient’s employment? Yes No *E. Did you complete a Workers’ Compensation claim form? Yes No
F. Date of first visit for this condition G. Frequency of subsequent visits: H. Date of most recent visit
Weekly Monthly Other
I. Describe planned course and duration of treatment

J. Hospitalization? K. Date Admitted Date Discharged L. Surgery? M. Date Surgery Completed/Scheduled

Yes No Yes No
N. Reason/Surgery Type O. Surgery/Post-Surgery Complications?
Yes No If yes, please describe
4. Level of Functional Impairment Please attach recent chart notes/pertinent records.
A. Describe patient’s physical and/or mental limitations and restrictions (functional capacity).

B. Factors Delaying Recovery (if applicable)

C. How long do you expect these limitations and restrictions to impair your patient?
Date expected to return to work______________ Unable to determine, follow up in______ weeks Permanently
*D. Is the patient competent to manage insurance benefits? Yes No
If no, is the patient competent to appoint someone to help manage the insurance benefits? Yes No
5. Physician Information Please type or print.
Name of physician completing this form Specialty Phone No.
( )
Address City State ZIP Fax No.
( )
*Acknowledgement – I certify that the answers I have made to the above questions are complete and true to the best of my knowledge and belief. I
acknowledge that I have read the fraud notice on page 2 of this form.

Signature Date

SI 14560 L# 389364 1 of 2 CL# (5/13)

Standard
Standard Insurance
Insurance Company
Company
866.756.8116
866.756.8116Tel Tel
866.751.5174 Fax
866.751.5174 Fax Disability Claim/Family Medical Leave
PO
PO Box
Box3877
3877Portland OR 97208
Portland OR 97208 Attending Physician’s Statement

Some states require us to provide the following information to you:

ALABAMA, MARYLAND AND RHODE ISLAND RESIDENTS

Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly
or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.

CALIFORNIA RESIDENTS
For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false
or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

COLORADO RESIDENTS
It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance,
and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or
misleading facts or information to the policyholder or claimant for the purpose of defrauding or attempting to defraud the
policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the
Colorado division of insurance within the department of regulatory agencies.

DISTRICT OF COLUMBIA RESIDENTS

WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or
any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false
information materially related to a claim was provided by the applicant.

FLORIDA RESIDENTS
Any person who knowingly and with intent to injure, defraud or deceive an insurance company, files a statement of claim or an
application containing false, incomplete or misleading information is guilty of a felony of the third degree

NEW JERSEY RESIDENTS

Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and
civil penalties.

NEW YORK RESIDENTS

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance
or statement of claim, containing any materially false information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to civil
penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

PENNSYLVANIA RESIDENTS
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance
or statement of claim containing any materially false information or conceals for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal
and civil penalties.

ALL OTHER RESIDENTS

Some states require us to inform you that any person who knowingly and with intent to injure, defraud or
deceive an insurance company, or other person, files a statement containing false or misleading information
concerning any fact material hereto commits a fraudulent insurance act which is subject to civil and/or
criminal penalties, depending upon the state. Such actions may be deemed a felony and substantial fines
may be imposed.

SI 14560
L# 389364 2 of 2 CL# (5/13)
 a
Standard Insurance Company
866.756.8116 Tel 866.751.5174 Fax
PO Box 3877 Portland OR 97208 Return to Work Authorization

To Be Completed By Employee
Patient Name Leave # Date of Birth
Olivia Sapp 389364
I authorize Standard Insurance Company to share information collected with this form with my employer for purposes of evaluating my return
to work status.
Patient’s Signature Date

To Be Completed By Health Care Provider

NOTE TO HEALTH CARE PROVIDER: If the employee has provided you with a list of his/her essential job functions or his/her job description,
please answer these questions based upon that information. If the employee has not provided you with that information, please answer these
questions based upon the employee’s own description of his/her job functions. Limit your responses to the condition(s) for which the
employee has been on leave.

NOTE: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II
from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this
law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical
information. “Genetic Information” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or
family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and
genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or
family member receiving assistive reproductive services.

Have you been provided with a list of essential job functions or job description to consider in your assessment of the employee’s
ability to return to work?
… Yes
… No
Is the above named employee fit to resume work functions?
… Yes, effective date:
… No
If no, please provide a brief description of any work restrictions and/or essential work functions the employee is not able to perform.

Name of Health Care Provider

Address City State ZIP

Phone No. Specialty/Type of Practice

Signature of Health Care Provider Date

SI 14562 L# 389364 CL# (6/12)

Standard Insurance Company a
866.756.8116 Tel 866.751.5174 Fax
Disability Insurance
PO Box 3877 Portland OR 97208 Claim Form Fraud Notices

Some states require us to provide the following information to you:

CALIFORNIA RESIDENTS
For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false
or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

COLORADO RESIDENTS
It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance,
and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or
misleading facts or information to the policyholder or claimant for the purpose of defrauding or attempting to defraud the
policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the
Colorado division of insurance within the department of regulatory agencies.

FLORIDA RESIDENTS
Any person who knowingly and with intent to injure, defraud or deceive an insurance company, files a statement of claim or an
application containing false, incomplete or misleading information is guilty of a felony of the third degree.

MARYLAND RESIDENTS
Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly
and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.

NEW JERSEY RESIDENTS

Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and
civil penalties.

NEW YORK RESIDENTS

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance
or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning
any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to
exceed five thousand dollars and the stated value of the claim for each such violation.

PENNSYLVANIA RESIDENTS
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance
or statement of claim containing any materially false information or conceals for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal
and civil penalties.

ALL OTHER RESIDENTS

Some states require us to inform you that any person who knowingly and with intent to injure, defraud
or deceive an insurance company, or other person, files a statement containing false or misleading
information concerning any fact material hereto commits a fraudulent insurance act which is subject to
civil and/or criminal penalties, depending upon the state. Such actions may be deemed a felony and
substantial fines may be imposed.

(5/09)
 a

EMPLOYEE
ASSISTANCE
PROGRAM
Help is available for personal
or job-related problems.
Grief. Job-related concerns. Marital dis- How much will EAP cost me?
cord. Family crisis. Interpersonal conflict. Your EAP benefit provides six visits per year with a
Anger management. Compulsive gam- therapist at no cost to you. If you require addi-
bling. Substance abuse. Financial and tional sessions beyond six visits, your therapist will
legal issues. These problems and more can facilitate arrangements for continued care based
create stress that affects your behavior and on your needs.
relationships with family, friends, co-workers,
supervisors and others – stress that can ultimately How to Reach Us
threaten your physical and mental well-being, Call 312-7001 or 1-800-435-7912 for more
as well as your job performance. If you are ex- information or to set up a free assessment.
periencing personal or work place problems,
Phoebe Behavioral Health Center offers an Em- How will EAP benefit me?
ployee Assistance Program (EAP) that can help
■ Help you create better coping skills
you.
■ Help you build confidence
■ Help you develop skills to better manage your
What is EAP?
personal stress
EAP offers counseling services to help you and
■ Help you improve interpersonal relationships
your eligible dependents to work through prob-
■ Help you improve focus and concentration
lems. EAP is provided by our Behavioral Health
Center’s licensed and or certified therapists, who
Professional and Confidential
adhere to the highest professional and ethical
All treatments and services are conducted in
standards.
a private and confidential setting and are
Phoebe Behavioral Health Center provides:
provided by experienced staff, who adhere
■ confidential assessment
to the highest professional and ethical standards.
■ short-term counseling
■ referral and follow-up services

How can I get EAP services?

You can self-refer by calling 312-7001 or
1-800-435-7912 and making an appointment
or your supervisor may recommend the EAP as
an approach to maintaining your well-being.
Regular office appointments are scheduled from
8 a.m - 5 p.m. Monday - Friday. Services are avail-
able 24 hours a day, 365 days a year. If the prob-
lem is urgent but not an emergency, an
appointment will be scheduled within 48 hours.
EAP services are offered at the Behavioral Health
Center at Phoebe, located in the 500 Building,
500 West Third Avenue.
 a

Exclusively for Health Advocate Members 24/7 866.695.8622

Support
HealthAdvocate.com/members

Taking Work Leave?

Let us be a resource

When you go on family medical, disability or maternity/paternity leave,

there’s no need to worry about healthcare and insurance-related
issues. You can take comfort in knowing that your Health Advocate
benefit, provided through The Standard, offers you unlimited access
to a Personal Health Advocate who can to handle your questions and
concerns. You’ll be free to focus on yourself and your loved ones.

Our Experts are your Go-to Resource

Family medical or disability issues New moms and dads
• Assist with Family and Medical Leave Act-related • Answer questions about newborns such as feeding,
issues such as caring for a sick parent rer bathing and sleeping issues, common conditions, when
to call the doctor and more
• Clarify a diagnosis, research the latest treatments,
and if needed, find a doctor for a second opinion • Find care or services for babies with special health needs
• Explain adding your baby to your health plan. Inform you
• Locate the right doctors, hospitals and other
of the timeframe and help you with the paperwork
providers. We’ll even make the appointments

• Research caregiver and community resources Remember... Your Personal Health Advocate can help
such as in-home care and eldercare services you while you are on work leave and assist you with a
variety of other healthcare and insurance-related issues.
• Coordinate between your doctors and health plan. Eligible employees, their spouses, dependent children,
For example, if you need to resolve a disability issue, parents and parents-in-law are all covered. Just call
we can help with the required paperwork or email answers@HealthAdvocate.com.
• Find affordable options for durable medical or
other special equipment

• Address billing or claims issues

©2013 Health Advocate, Inc. HA-CM-1302019-1FLY

 a

Phoebe Putney Health System

Authorization to Obtain and Release Information
I AUTHORIZE THESE PERSONS having any records or knowledge of me or my health:
• Any physician, medical practitioner or health care provider.
• Any hospital, clinic, pharmacy or other medical or medically related facility or association.
• Kaiser Permanente.
• Any insurance company or annuity company.
• Any employer, policyholder or plan sponsor.
• Any organization or entity administering a benefi t or leave program (including statutory benefi ts) or an annuity program.
• Any educational, vocational or rehabilitation counselor, organization or program.
• Any consumer reporting agency, fi nancial institution, accountant, or tax preparer.
• Any government agency (for example, Social Security Administration, Public Retirement System, Railroad Retirement Board, Workers’
Compensation Board, etc.).
TO GIVE THIS INFORMATION:
• Charts, notes, x-rays, operative reports, lab and medication records and all other medical information about me, including
medical history, diagnosis, testing and test results. Prognosis and treatment of any physical or mental condition, including:
• Any disorder of the immune system, including HIV, Acquired Immune Defi ciency Syndrome (AIDS) or other related
syndromes or complexes.
• Any communicable disease or disorder.
• Any psychiatric or psychological condition, including test results, but excluding psychotherapy notes. Psychotherapy notes
do not include a summary of diagnosis, functional status, the treatment plan, symptoms, prognosis and progress to date.
• Any condition, treatment, or therapy related to substance abuse, including alcohol and drugs.
and:
• Any non-medical information requested about me, including such things as education, employment history, earnings or
fi nances, return to work accommodation discussions or evaluations and eligibility for other benefi ts or leave periods
including but not limited to claims status, benefi t amount, payments, settlement terms, effective and termination dates,
plan or program contributions, etc.
TO STANDARD INSURANCE COMPANY, THE STANDARD LIFE INSURANCE COMPANY OF NEW YORK, THE STANDARD
BENEFIT ADMINISTRATORS AND THEIR AUTHORIZED REPRESENTATIVES (referred to as “The Companies”, individually
and collectively), AND MY EMPLOYER’S ABSENCE MANAGEMENT PROGRAM ADMINISTRATOR (“Absence Manager”).
• I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization
and I instruct the persons and organizations identified above to release and disclose my entire medical record without restriction.
• I understand that each of The Companies and Absence Manager will gather my information only if they are administering
or deciding my disability or leave of absence claim(s), and will use the information to determine my eligibility or entitlement
for benefi ts or leave of absence.
• I understand that I have the right to refuse to sign this authorization and a right to revoke this authorization at any time
by sending a written statement to The Companies and Absence Manager, except to the extent the authorization has been
relied upon to disclose requested records. A revocation of the authorization, or the failure to sign the authorization, may
impair The Companies and Absence Manager’s ability to evaluate or process my claim(s), and may be a basis for denying
or closing my claim(s) for benefi ts or leave of absence.
• I understand that in the course of conducting its business The Companies and Absence Manager may disclose to other
parties information about me. They may release information to a reinsurer, a plan administrator, plan sponsor, or any person
performing business or legal services for them in connection with my claim(s). I understand that The Companies and Absence
Manager will release information to my employer necessary for absence management, for return to work and accommodation
discussions, and when performing administration of my employer’s self-funded (and not insured) disability plans.
• I understand that The Companies and Absence Manager comply with state and federal laws and regulations enacted to
protect my privacy. I also understand that the information disclosed to them pursuant to this authorization may be subject to
redisclosure with my authorization or as otherwise permitted or required by law. Information retained and disclosed by The
Companies and Absence Manager may not be protected under the Health Insurance Portability and Accountability Act [HIPAA].
• I understand and agree that this authorization as used to gather information shall remain in force from the date signed below:
• For Standard Insurance Company, the duration of my claim(s) or 24 months, whichever occurs fi rst.
• For The Standard Life Insurance Company of New York, the duration of my claim(s) or 24 months, whichever occurs fi rst.
• For The Standard Benefit Administrators, the duration of my claim(s) administered by The Standard Benefit
Administrators or 24 months, whichever occurs fi rst.
• For Absence Manager, 24 months.
• I understand and agree that The Companies and Absence Manager may share information with each other regarding my
disability and leave of absence claim(s). This authorization to share information shall remain valid for 12 months from the
date signed below.
• I acknowledge that I have read this authorization and the New Mexico notice on page 2. A photocopy or facsimile of this
authorization is as valid as the original and will be provided to me upon request.

Name (please print) Social Security No.

Signature of Claimant/Representative Date

If signature is provided by legal representative (e.g., Attorney in Fact, guardian or conservator), please attach documentation of legal status.
SI 2047-156262-AUTH 1 of 3 (10/13)
 Phoebe Putney Health System
Authorization to Obtain and Release Information

Standard Insurance Company is a licensed insurance company in all states except New York. The Standard Life Insurance
Company of New York is an insurance company licensed only in New York. An absence manager may be hired by your employer
and may be one of The Companies.

FOR RESIDENTS OF NEW MEXICO

The state of New Mexico requires Standard Insurance Company to provide you with the following information pursuant to its
Domestic Abuse Insurance Protection Act.

The Authorization form allows Standard Insurance Company to obtain personal information as it determines your eligibility for
insurance benefits. The information obtained from you and from other sources may include confidential abuse information.
“Confidential abuse information” means information about acts of domestic abuse or abuse status, the work or home address or
telephone number of a victim of domestic abuse or the status of an applicant or insured as a family member, employer or
associate of a victim of domestic abuse or a person with whom an applicant or insured is known to have a direct, close personal,
family or abuse-related counseling relationship. With respect to confidential abuse information, you may revoke this authorization
in writing, effective ten days after receipt by Standard Insurance Company, understanding that doing so may result in a claim
being denied or may adversely affect a pending insurance action.

Standard Insurance Company is prohibited by law from using abuse status as a basis for denying, refusing to issue, renew or
reissue or canceling or otherwise terminating a policy, restricting or excluding coverage or benefits of a policy or charging a
higher premium for a policy.

Upon written request you have the right to review your confidential abuse information obtained by Standard Insurance Company.
Within 30 business days of receiving the request, Standard Insurance Company will mail you a copy of the information pertaining
to you. After you have reviewed the information, you may request that we correct, amend or delete any confidential abuse
information which you believe is incorrect. Standard Insurance Company will carefully review your request and make changes
when justified. If you would like more information about this right or our information practices, a full notice can be obtained
by writing to us.

If you wish to be a protected person (a victim of domestic abuse who has notified Standard Insurance Company that you are
or have been a victim of domestic abuse) and participate in Standard Insurance Company’s location information
confidentiality program, your request should be sent to Standard Insurance Company.

SI 2047-156262-AUTH 2 of 3 (10/13)
 Phoebe Putney Health System
Optional Authorization to Release Information

If I am an enrolled Provectus member, I authorize Standard Insurance Company (The Standard) to release to Provectus, for
the administration of other benefits and coverage, the information contained in my file, which may include my entire medical
history, as applicable to me. I authorize Provectus to use this information for return to work, wellness, and other evaluations
related to services for which I am enrolled to receive from Provectus. I expect Provectus to retain and disclose this information
consistent with any applicable privacy laws.

I have the right to revoke this authorization at any time by sending a written statement to Standard Insurance Company, except
to the extent the authorization has been relied upon to disclose requested records.

I understand and agree that this Optional Authorization shall remain in force 12 months from the date signed below.

Name (please print) Social Security No.

Signature of Claimant/Representative Date

If signature is provided by legal representative (e.g., Attorney in Fact, guardian or conservator), please attach documentation of legal status.

SI 2047-156262-AUTH 3 of 3 (10/13)
 A

Leave of Absence/STD Checklist

Please use this checklist as a guide to assist you with managing your Leave of Absence (LOA) and Short Term
Disability (STD) Benefits.

Within 5 Days of receiving your Leave of Absence request and this checklist:
Submit the enclosed Authorization to Release Information form to The Standard.

At the start of your leave:

Within 3 Days of the start of your leave
Contact The Standard and your immediate leader to confirm your leave has started.

Within 15 days of the start of your leave

Submit the Attending Physician Statement form to The Standard. The form must be completed by
your physician.
Please Note: Your Short-Term Disability (STD) benefits, if eligible, will not begin until the Attending
Physician Statement is received and your benefits are approved by The Standard. Any delay in your
physician returning this form will impact when your STD benefits begin.

During Leave of Absence:

Respond promptly to information requests from The Standard.

Provide leave status updates/changes (i.e. extension, cancellation, etc.) to The Standard,
Human Resources and Supervisor.

For Intermittent FMLA Requests:

For each time or day you miss work, you must inform The Standard within 48 hours for the time to be
considered protected under FMLA and your immediate leader based upon company absence and/or
tardy procedure/policy in order to avoid disciplinary action.

If You Need More Time Off Than Expected:

Contact The Standard and your immediate leader as soon as you find out you are not able to return to
work on the original date reported to The Standard.

Returning From a Leave of Absence:

5 Days Before Returning to Work (if you are on leave due to your own serious health condition):
Submit the Return to Work Authorization form to Phoebe Main Human Resources prior to, or
immediately upon your return to work. This form must be completed by your physician. The Standard
will mail you this form 14 days prior to the date they show you are scheduled to return to work.

5 Days Before Returning to Work

Contact your immediate leader to discuss your return to work.

Contact the Benefits Department prior to returning to work if benefit deductions were not paid.

1 1.2017
 Important Numbers to Remember

The Standard Phoebe Putney Health System

Phone: 1-866-756-8116 Phoebe Main, Worth & Sumter
Hours: M- F, 7a.m.-7p.m. EST Phone: 229-312-4349
Email: absence@standard.com Email: LOA@ppmh.org
Fax: 866-751-5174 Fax: 229-312-4345

2 1.2017