Letter Request

Please note: This request form is for patients only.

Complete the following form and submit by fax (251)410-3724, or email to letter_request@alortho.com.

Please note that processing time is 3-5 business days. Letters requested are not guaranteed. You will receive a phone call when the letter is ready, or if it has been denied.

Explanation of letters:

  • JURY DUTY EXCUSE: Letter requesting temporary postponement or deferment from jury duty due to your current orthopaedic issue. Once completed, the letter will be faxed to the court and the original will be mailed to you. Do not assume you are automatically excused or deferred. It is your responsibility to contact the court to obtain status of the request.
  • SURGERY EXCUSE: Verification of upcoming surgery dates.
  • WORK/SCHOOL EXCUSE: Verification of current out of work/school status as documented by your physician. If you are requesting to be off, you must contact your physician. Do not use this form to request to be off work. This is for documented status only.
  • RESTRICTION VERIFICATION: Verification of documented restrictions.
  • RELEASE TO WORK: Letter stating you have been released to return to work with or without restrictions.
  • MEDICATION VERIFICATION: Letter verifying documented medication provided by Alabama Orthopaedic Clinic, PC.
  • OTHER: What does your letter need to say?

 

Letter Request Form

Physician
Request Date

Patients Name
DOB

Chart Number
Phone Number

Select one:
 Mail to Patient Call When Ready Mail to Outside Party

Fax To
Attention

Address to mail letter

Please state in letter

  • Completion of letter: 3-5 business days
  • Patient will be contacted at the above number when complete/ready.