Short-Term Disability Claim Form - The Epic Life Insurance Company Page 2
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2TOTAL DISABILITY
20. What is the patient’s current treatment plan (i.e. physical therapy, number of visits per week, length of session etc.)?
21. Date you advised your patient to stop working?
22. Are there any additional medical conditions or complications affecting your patient’s recovery?
Yes
No
If yes, please explain.
23. What is the patient’s expected return to work date?
24. Is the patient a candidate for partial disability?
Yes
No If yes, refer to PARTIAL DISABILITY section below.
PARTIAL DISABILITY
25. What is the patient’s current treatment plan (i.e. physical therapy, number of visits per week, length of session etc.)?
26. Date you advised your patient to return to work part-time?
27. What is the number of days or hours the patient can resume part-time work?
28. What is the patient’s expected return to work date on a full-time basis?
MATERNITY
29. Is this disability due to pregnancy?
Yes
No
30. Date of Last Menstrual Period:
31. If disability is prior to delivery, what are the complicating factors (be specific) and expected date of delivery?
32. Date you advised your patient to stop working?
33. What was the patient’s expected date of delivery:
Actual date of delivery:
34. Type of delivery?
Vaginal
C-section
35. What is the patient’s expected return to work date?
PHYSICIAN INFORMATION
Physician’s Signature
Date
Physician Name (Please Print)
Physician Address
City
State
Zip
Physician Telephone Number
Physician Fax Number
Medical Records Department Fax Number
MAIL OR FAX FORM TO:
EPIC Specialty Benefits
Attention: Life & Disability Claims
P.O. Box 8430
Madison, WI 53708-8430
Fax: 608-223-2179
29541-088-1607
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