Medical Documentation

Leave Bank Medical Documentation Requirements:

Your treating physician must complete the Confidential Medical Documentation form. It should:

  • Include detailed information.
  • Be stamped by the physician’s office or include a letter on the physician’s letterhead.
  • Be submitted to the Leave Bank Office via:

All medical documentation will be kept confidential.

Cases that do not require medical documentation:

  • Appeals
  • Psychological/Psychiatric conditions

If the medical provider and patient are located outside of the USA, submit medical documentation regardless of the type of medical emergency.

Additional information can be found on the Leave Bank Recipient Homepage and in the Form 2923, Authorization for Disclosure of Information, instructions.

For questions, email or call (301) 443-8393.

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