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Click ‘Get Form’ to open it in the editor.
Begin with Section 1, where you will enter your Employee Information. Fill in your name, date of birth, gender, and IRS office details accurately.
In Section 2, identify the forms you are including with your medical review request by checking all applicable boxes. This ensures that FOH has all necessary documentation.
Proceed to Section 3 to specify the type of service you are requesting. Select only one option that best fits your needs: Ergonomic Assessment, Family Medical Leave Act, or Reasonable Accommodation.
Section 4 provides links to appropriate IRS Points of Contact (POCs) for your medical review request. Make sure to access these links for further assistance.
Finally, complete Section 5 with the form submittal information. Include who is submitting the form, their contact details, and ensure all fields are filled out correctly before submission.

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