Short-Term Disability Claim Form Page 7
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FAX (402) 997-1865
Email
Form must be completed in full at no expense to Mutual of Omaha
Section 3 – Attending Physician’s Statement (Answer all questions to avoid delay)
Employer Name
Group ID Number
Name of Patient (Last, First, MI) – Please Print
Date of Birth
Employee’s Phone Number
Employee Address
Employee City
Employee State
Employee ZIP
Diagnoses
ICD-9 Code(s)
Symptoms
Date symptom first appeared
Initial date of treatment:
Last date of treatment:
Next date of treatment/office visit:
Is disability due to:
Accident/Injury
Sickness
Is the disability work related?
Yes
No
n
n
n
n
If applicable, list the surgical procedure(s) – Describe fully and provide dates if any.
If disability is due to Pregnancy, please provide the information below:
Date of Last Monthly Period
Expected Date of Delivery
Expected Type of Delivery
Vaginal
Cesarean Section
n
n
Actual Date of Delivery
Actual Type of Delivery
Vaginal
Cesarean Section
n
n
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
Date treated
Name of Hospital
Name of Physician
Emergency Room?
Yes
No
n
n
Did another physician treat or will be
Date treated
Physician’s Name and Address
treating the patient?
Yes
No
n
n
Was the patient hospital confined?
Date Confined In Hospital:
Name of Hospital
Yes
No
From______________ To________________
n
n
Did patient have outpatient surgery in a hospital
Date of Surgery
Name of Facility
or ambulatory surgical center?
Yes
No
n
n
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)
Lifting
Carrying
_____ Sitting
_____ Kneeling
_____ R: Finger Dexterity
__________1-5 lbs.
__________1-5 lbs.
_____ Total time on feet
_____ L: Finger Dexterity
}
__________6-10 lbs.
__________6-10 lbs.
_____ Standing
_____ Inside
_____ R: Below Shoulder
__________11-25 lbs.
__________11-25 lbs.
_____ Walking
_____ L: Below Shoulder
Reaching
__________26-50 lbs.
__________26-50 lbs.
_____ Bending
_____ Outside
_____ R: Above Shoulders
__________51-100 lbs.
__________51-100 lbs.
_____ Squatting
_____ Working with
_____ L: Above Shoulders
Others
__________Over 100 lbs.
__________Over 100 lbs.
_____ Stooping
_____ Other (explain)__________________________________
Please notify us if the Employee returns to work after the submission of this form.
MUG6110A_0114
Page 5 of 6
Form continued on Page 6
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