OB/GYN FMLA form information - Mercy 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient’s name and date of birth in the designated fields. If you are filling this out for a spouse or significant other, provide their name and date of birth as well.
3. Fill in your address, city, and zip code accurately to ensure proper communication.
4. Provide your home and cell phone numbers. Indicate whether you would like messages left regarding your paperwork.
5. Specify the beginning date of the leave requested and detail the reason for the leave, such as pregnancy or surgery.
6. If applicable, indicate the type of delivery (Vaginal/Cesarean Section) and provide your estimated due date if you have not delivered yet.
7. Include any necessary fax number for sending paperwork and specify if you would like originals mailed to you.
8. For surgery-related requests, enter the date of surgery and anticipated amount of leave needed.
9. Sign and date the authorization section allowing Mercy Clinic to release information related to your request.
10. Finally, confirm payment details by selecting payment type and amount before submitting your form.

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