Short-Term Disability Claim Form - The Epic Life Insurance Company printable pdf download

Short-Term Disability Claim Form - Update

Attending Physician Statement

1. Patient’s Name

2. Identification Number

3. Date of Birth

4. Date you first treated this patient

5. Date of most recent treatment

6. Date of next visit

7. Date sickness or injury began

8. Patient’s Height

Patient’s Weight

9. Diagnosis code (ICD-9 code)

10. Description

11. Medication(s) prescribed

12. Is the condition primarily related to:

Employment

Illness

Mental Disorder

Alcohol or Drug Dependence

(check all that apply)

MVA

Pregnancy

Injury

13. If patient was hospitalized, please provide admit and discharge dates: Admit

Discharge

14. Has surgery been done?

Yes

If yes, date of surgery

CPT Code or Description of Procedure

15. Is this illness or injury intentionally self-inflicted or attempted suicide?

Yes

If yes, please provide details:

16. Is this illness or injury resulting from weight control or treatment of obesity not caused by an organic condition?

Yes

If yes, please describe your objective findings:

17. To the best of your knowledge, has the patient been diagnosed, received medical care, services, treatment, advice or recommendations for this

condition prior to this disability onset?

Yes

If yes, please provide the name, address and telephone number of the referring physician.

18. Physical restrictions/limitations (as defined in the Federal Dictionary of Occupational Titles)

Class 1-No limitation of functional capacity: capable of heavy work. No restrictions (0-10%)

Class 2-Medium manual activity (15-30%)

Class 3-Slight limitation of functional capacity: capable of light work. (35-55%)

Class 4-Moderate limitation of functional capacity: capable of clerical/administrative (sedentary) activity. (60-70%)

Class 5-Severe limitation of functional capacity: incapable of minimum (sedentary) activity. (75-100%)

What are the patient’s physical restrictions/limitations?

19. Mental impairments (if applicable)

Class 1-Patient is able to function under stress and engage in interpersonal relations (no limitations).

Class 2-Patient is able to function in most stress situations and engage in most interpersonal relations (slight limitations).

Class 3-Patient is able to engage in only limited stress situations or engage in limited interpersonal relations (moderate limitations).

Class 4-Patient is unable to engage in stress situations or engage in interpersonal relations (marked limitations).

Class 5-Patient has significant loss of physiological, psychological, personal and social adjustment (severe limitations).

What are the patient’s mental impairments?

For TOTAL DISABILITY, PARTIAL DISABILITY, or MATERNITY claims, please complete the appropriate section on the reverse side of this form.

Short-Term Disability Claim Form - The Epic Life Insurance Company

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