Global Neurosciences Institute  |  Phone: 844-464-6387  |  medicalrecords@gnineuro.org

This is an intake request, not a completed medical certification or an approval of leave or benefits. Include all pages of your paperwork, and complete and sign the patient/employee sections before submitting when possible. Do not complete the healthcare provider sections.

The standard processing fee is $50, paid securely at the end of this form for a new request or recertification. Processing generally takes 7 to 10 business days after all required information and payment are confirmed. Additional information or an office visit may be needed. Tell us your employer's actual deadline, especially if it is soon.

Copies of existing medical records are free. Please use our Medical Records request for those.

Complete the leave questions for a new request or a recertification/extension. For a copy, correction, or update to a pending request, provide only the information relevant to that request.

Do not provide Social Security numbers, payment-card information, account passwords, or unrelated medical information in the request fields.

To send completed paperwork directly to an employer, benefits administrator, caregiver, or another outside recipient, GNI must have a valid authorization or another reviewed legal basis for release. Provide a separately signed authorization or tell us where it can be found. GNI will review the actual authorization before release. Selecting a recipient or signing this intake request does not replace a valid release authorization. You may choose return to the patient instead of direct employer delivery.

The standard fee is $50 for a new FMLA, disability, or employment-related form-completion request. A recertification, extension, or materially new request may require a new fee. GNI will review coordinated packets and confirm any additional charge before collecting it. Payment is required before substantive form processing begins, unless an approved exception applies.

The standard fee is non-refundable once form review begins, even when the provider cannot support the requested certification or an office visit is needed. This fee is paid for review and completion work; it does not purchase a particular medical opinion. We do not automatically charge again for additional information on a pending request, correction of a GNI error, or a copy of an already completed form. If the request involves new clinical work, we will explain the applicable fee before collecting it.

Standard processing is generally 7 to 10 business days after payment and all required information are confirmed. An appointment, missing information, or third-party clarification may affect timing. Your provider determines the medically supported answers; your employer or benefits administrator determines leave or benefit approval.

Expedited processing is not guaranteed. An additional $50 applies only if GNI accepts the expedited request and communicates a target date. We will not automatically charge a rush fee because the deadline is close.

I confirm that the information I have provided is accurate to the best of my knowledge.

For a new request or recertification: I have read the processing and fee terms, including when payment is required and when a fee becomes non-refundable.

For a request requiring clinical review: I understand that my provider determines what is medically supported and that submitting or paying for this request does not guarantee leave or benefit approval.

The signature below acknowledges this intake request only. It is not a release authorization.

Questions? Contact medicalrecords@gnineuro.org or call 844-464-6387.