Claimant'S Supplementary Statement Page 2
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1
2ATTENDING PHYSICIAN’S SUPPLEMENTARY STATEMENT —
PLEASE PRINT
Please return completed form to your patient. The patient is responsible for securing this form and for charges made for its completion.
PATIENT NAME
A) PRIMARY
1. DIAGNOSIS OF PRESENT CONDITION
(SPECIFIC MEDICAL DIAGNOSIS)
B) SECONDARY
(IF APPLICABLE)
DESCRIBE
2. INDICATE COMPLICATIONS OR NEW
INDEPENDENT CONDITIONS, SUCH AS
SURGERY, WHICH MAY PROLONG THE
DISABILITY.
DATE
(MM/DD/YYYY)
3. DATE OF LATEST ATTENDANCE?
OTHER?
(SPECIFY)
o
o
YES
WEEKLY
IF YES, STATE FREQUENCY OF VISITS (ON RIGHT)
4. HAVE YOU BEEN ACTIVELY SUPERVISING
PATIENT’S CARE?
o
o
NO
MONTLY
IF NO, COMMENT IN REMARKS (#9)
DATE OF LATEST TREATMENT
(MM/DD/YYYY)
o
YES
IF YES, STATE DATE OF LATEST TREATMENT
5. IS PATIENT FOLLOWING RECOMMENDED
TREATMENT PROGRAM?
o
NO
IF NO, COMMENT IN REMARKS (#9)
DATE
(MM/DD/YYYY)
o
YES
IF YES, GIVE APPROXIMATE DATE WHEN PATIENT SHOULD BE ABLE TO RETURN TO WORK.
6. TO THE BEST OF YOUR KNOWLEDGE, IS
DATE
(MM/DD/YYYY)
o
THE PATIENT TOTALLY DISABLED (UNABLE
NO
IF NO, ON WHAT DATE COULD THE PATIENT HAVE RETURNED TO WORK?
TO WORK/PERFORM USUAL ACTIVITIES)?
o
# OF WKS
INDEFINITE
IF INDEFINITE, GIVE THE ESTIMATED NUMBER OF ADDITIONAL WEEKS BEFORE SUCH RETURN
FROM
TO
7. HOW LONG WAS OR WILL PATIENT BE
(MM/DD/YYYY)
(MM/DD/YYYY)
PARTIALLY DISABLED (ABLE TO WORK
PART-TIME AT OWN OCCUPATION)?
8. IS PATIENT A SUITABLE CANDIDATE FOR A
o
o
YES
NO
REHABILITATION PROGRAM?
9. REMARKS. PLEASE PROVIDE COMMENTS
AND FURTHER DETAILS WHICH YOU FEEL
WOULD BE HELPFUL.
PHYSICIAN’S NAME
TELEPHONE NUMBER
ADDRESS
POSTAL CODE
PHYSICIAN’S SIGNATURE
DATE
(MM/DD/YYYY)
294441 (01/2013)
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