Application For Short Term Disability Income Benefits Attending Physician'S Statement Form Page 2

Moderate impairment in occupational functioning. Limited in performing some occupational duties.

Major impairment in several areas – work, family relations. Avoidant behavior, neglects family, is unable to work.

Inability to function in almost all areas.

Date patient ceased work due to this impairment:_____________

If physical or psychiatric limitations exist, indicate the date limitations have lasted, or will last through: ______________

Attending Physician’s Name

Social Security Number or E.I.N. Number:

Address: (Street, City, State & Zip Code)

Telephone Number

Fax Number

(

)

(

)

Degree________________________________ Specialty ______________________________________

Signature___________________________________________________ Date Signed______________

0 votes

Parent category: Legal