Form guides

The forms patients bring you, explained

Leave, disability, workers' compensation and parking forms all have a part only the clinician can complete. Each guide covers who fills in which part, walks through yours in the form's order, and links to the official source.

Scribeable fills these forms from your visit note. It writes only what the note states and leaves the rest blank for you. You review it, sign it, and send it on.

Federal

FMLA, employee (WH-380-E)U.S. Department of Labor, Wage and Hour DivisionReturned to the patient, who gives it to the employer
FMLA, family member (WH-380-F)U.S. Department of Labor, Wage and Hour DivisionReturned to the patient or the employee, who gives it to the employer

New York

NY disability benefits (DB-450)New York State Workers' Compensation BoardReturned to the patient within seven days, who sends it to the employer's carrier
NY workers' comp narrative (CMS-1500 template)New York State Workers' Compensation BoardAttached to the CMS-1500 bill sent through a Board-approved electronic submission partner

California

CA workers' comp progress report (PR-2)California Division of Workers' CompensationSent to the claims administrator
CA SDI Part B answers (DE 2501)California Employment Development DepartmentFor the clinician: copy into SDI Online or onto the EDD-issued original form

Florida

FL disabled parking permit (HSMV 83039)Florida Department of Highway Safety and Motor VehiclesReturned to the patient, who files it with the county tax collector