Application For Short Term Disability Income Benefits Attending Physician'S Statement Form
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1
2APPLICATION FOR SHORT TERM DISABILITY INCOME BENEFITS
ATTENDING PHYSICIAN’S STATEMENT
Section IV
HISTORY
Patient’s Name
Social Security Number
Date of Birth
Is condition due to an illness or an injury that is work related
Height
Weight
Patient’s condition is the result of:
illness
Injury
Pregnancy
Mental/ Nervous Condition
If pregnancy, what is the expected date of delivery? Month________ Day________ Year_________ LMP Date__________
DIAGNOSIS
Diagnosis (including any complications)
ICD9 Codes
Subjective Symptoms
Physical Findings (list all test results, or enclose results)
Test___________________ Date_________________ Results__________________
Test___________________ Date_________________ Results__________________
Blood Pressure (Systolic)_______________ (Diastolic)_______________ (Date)_____________
Remarks:
TREATMENT
Date of onset of this condition?
List all dates of treatment for this condition since patient ceased work
Date of next office
visit
Has patient been referred to any other physician?
Yes
No
If “Yes,” date(s)___________ ____________ _________
Name and address_____________________________________________________________
Specialty__________________
Nature of treatment for this condition (including surgery/medications)____________________________________________________
Was patient hospitalized for this condition?
Yes
No If “Yes,” date(s) admitted_______ date(s) discharged______________
Name and Address of Hospital(s)________________________________________________________________________________
Was surgery performed?
Yes
No If “Yes,” Date_________ Procedure______________________ CPT Code__________
Progress (please check one)
Recovered
Improved
Unchanged
Retrogressed
IMPAIRMENT
What are the patient’s current physical limitations and restrictions?
No limitation of functional capacity; capable of heavy work, no restrictions.
(Lifting 100 lbs. maximum with frequent lifting and/or carrying objects weighing up to 50 lbs.)
Medium manual activity
(Lifting 50 lbs. maximum with frequent lifting and/or carrying of objects weighing up to 25 lbs.)
Slight limitation of functional capacity; capable of light work
(Lifting 20 lbs. maximum with frequent lifting and/or carrying of objects weighing up to 10 lbs. Even though the weight lifted
May be only a negligible amount a job is in the category when it involves sitting most of the time with a degree of pushing and
Pulling of arm and/or leg controls, or when it requires walking or standing to a significant degree.)
Moderate limitation of functional capacity; capable of clerical/administrative (sedentary) activity
(Lifting 10 lbs. maximum and occasionally lifting and/or carrying articles. Although a sedentary job is defined as one which
Involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties.)
Severe limitation of functional capacity; incapable of minimal (sedentary) activity
What is the psychiatric impairment (if applicable)?
Inadequate information to make assessment
Essentially good functioning in all areas. Occupationally and socially effective.
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