Short-Term Disability Claim Form Page 2
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2FAX NUMBER (402) 997-1865
Must be completed in full at no expense to Mutual
Part III – Attending Physician’s Statement (ALL QUESTIONS MUST BE ANSWERED TO AVOID DELAY)
Employer Name
Policy Number
Name of Patient (Last, First, M.I.) – Please Print
Date of Birth
Diagnosis
ICD-9 Code
Symptoms
Date symptoms first appeared (Mo. Day Year)
Is disability due to:
Accident/Injury
Sickness
Work related?
Yes
No
■
■
If Disability is Due To Pregnancy, Please Provide the Information Below:
LMP: _____ Expected Date of Delivery: _____ Actual Date of Delivery: ______
Type:
C-Section
Vaginal
■
■
Name of Surgical Procedure (Describe fully and provide dates if any)
If any of the Following questions are answered “Yes,” then please provide the information to the right of that question.
Was the patient treated in an emergency room?
Date Treated in Emergency Room
Name of Hospital
Physician
Yes
No
■
■
Was the patient treated by another physician?
Date Treated
Physician’s Name and Address
Yes
No
■
■
Was the patient hospital confined?
Date Confined In Hospital
Name of Hospital
Yes
No
From__________________
To____________________
■
■
Did patient have outpatient surgery in a hospital
Date of Surgery
Name of Facility
or ambulatory surgical center?
Yes
No
■
■
Functional Limitations - Abilities
indicate frequency per day the listed activity can be performed.
Indicate longest single time duration each activity can be performed.
(n - never, o - occasional, f - frequent, c - constant)
_____ Sitting
_____ Kneeling
_____ R Finger Dexterity
}
Lifting
Carrying
_____ Total time on feet
_____ L
__________1-5 lbs.
__________1-5 lbs.
_____ Standing
_____ Inside
_____ R Below Shoulder
__________6-10 lbs.
__________6-10 lbs.
_____ Walking
_____ L
Reaching
__________11-25 lbs.
__________11-25 lbs.
_____ Bending
_____ Outside
_____ R Above Shoulders
__________26-50 lbs.
__________26-50 lbs.
_____ Squatting
_____ Working with _____ L
__________51-100 lbs.
__________51-100 lbs.
Others
_____ Stooping
_____ Other (explain)_____________________
__________over 100 lbs.
__________over 100 lbs.
Mental Limitations - Abilities
Excellent
Good
Fair
Guarded
Judgement/decision making
____
____
____
____
Deal with work stresses
____
____
____
____
Function independently
____
____
____
____
Concentration/attention span
____
____
____
____
Emotional liability
____
____
____
____
Patient follows recommendations
____
____
____
____
Caring for self/family
____
____
____
____
Estimate overall prognosis
____
____
____
____
The patient has been continuously disabled (unable to work) from ____________________________ to ____________________________
The patient should be able to work
Full-time
Part-time on (date)_________ or in
1 mth.
1-3 mths.
3-6 mths.
Other________
■
■
■
■
■
■
Remarks
Name of Attending Physician - Please Print
Tax Identification Number
Address (No., Street, City, State, ZIP Code)
Telephone Number
Fax Number
Signature of Attending Physician
Date Signed
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