Short-Term Disability Application / Extension Form

All blanks must be completed to process your request. Return this form to the ServiceCenter upon completion by physician.

EMPLOYEE INFORMATION Request Type: This is an initial request This is an extension request
Last First middle
Name: / Employee #:
Street: / CITY: State: Zip Code:
Home
Telephone#: ( ) - / Work
Telephone#: ( ) - / date of birth:
Position: home office Staff Store Mgmt. Division /Region Staff Primary MAINT. Certified Swing
What is your actual/anticipated last day worked? have you returned to work? Yes date NO
Is this disability the result of an accident at work? Yes No / If yes, has it been called into gallagher Bassett Yes No
(Store employees must have Operations Consultant or Operations Manager name)
immediate supervisor NAME: phone: ( ) -
State Disability Insurance (Complete this section only if you work in CA, NY, NJ, HI, or RI.)
Employees in California, New York, New Jersey, Hawaii or Rhode Island must apply for the State Disability Insurance (SDI) provided by these states.
Have you completed the form and applied for SDI with your appropriate state agency? YES NO
Patient Authorization
Until I return to work or my STD/medical claims/condition has been resolved, I hereby authorize the following 3 conditions:
  1. The undersigned physician to release to McDonald’s Corporation and/or MedAssist of Illinois, LLC any and all information, which they possess, which is pertinent to my STD/medical claims/condition. I understand that I may be charged a reasonable fee for the provider’s cost of sending copies of my medical data.
  2. MedAssist of Illinois, LLC to disclose to McDonald’s Corporation any and all information pertinent to my STD/medical claims/condition which MedAssist of Illinois, LLC may receive from the undersigned physician.
  3. McDonald's Corporation Welfare Benefit Plan to disclose any and all information permissible under HIPAA pertinent to my STD/medical claims/condition to MedAssist of Illinois, LLC and McDonald's Corporation. I understand that I have the right to revoke this authorization, which revocation would be effective only after received by McDonald's Corporation, that I may receive a copy of this authorization and that my benefits under the plan are not conditioned on this authorization.
I authorize McDonalds to automatically move me to a medical leave without pay should I exhaust my Short-Term Disability benefits and be eligible for such leave.
I agree that as a condition of receiving McDonald's STD benefits, benefits that I receive from other sources, including Long Term Disability, Social Security Disability, State Disability , Workers Compensation, or similar programs will be used to offset the total benefit payment paid by McDonald's Short Term Disability benefit. In addition, I agree to reimburse to McDonald's any payments made to me in excess of the McDonald's STD benefit (including STD overpayments by McDonald's). I authorize McDonald's to make any such repayment deductions from any money owed to me.
I understand that if my STD Leave also qualifies for Family and Medical Leave, then Family and Medical leave will run concurrently with STD leave. I understand that I have the right to revoke this authorization; such revocation would be effective only after being received by McDonald's Corporation. I understand that if I do not make my premium payment for my McDonald's current benefit coverages within 30 days of the due date, my coverage will cease as of the end of the month for which my last premium payment was made. If I am on Family and Medical Leave. I will receive notice within 15 days after the end of the grace period that my coverage will be terminated.
Employee Signature: / Date:
Attending Physician Information (Please complete all applicable sections and please be specific. Retain photocopy for your files and return completed form to patient.)
If pregnancy anticipated
Date of Delivery (EDC):
Medical facts
supporting absence:
Has patient ever had same
or similar condition before?:  Yes  No / If Yes, When:
Patient continuously and
totally unable to work?: From: To: / Expected date of return
to work (Best Estimate)?
If patient will be absent from work or other daily activities because of treatment on an intermittent or part-time basis, also provide estimate of probable number and interval between such treatments, actual or estimated dates of treatment if known, and period required for recovery if any:
Physician’s Name (Print): / Degree:
circle one: MD DO DC DDS DPM OD PHD
Address
Street: / City: / State: / Zip:
Telephone#: ( ) Fax #: ( ) / Physician’s
Office contact:
Physician’s Signature: / Date:

Please forward this completed form and all required attachments (if applicable) to: Form 3889 5/1/2007

McDonald’s Service Center Dept. 238, McDonald’s Corporation, 2111 McDonald’s Drive, Oak Brook, IL, 60523
Telephone #: (877) 623-1955 Fax #: (630) 623-5027