Short-Term Disability Claim Evaluation
Claimant Information
Full Name
Date of Birth
Employee ID
Department
Claim Details
Claim Date
Type of Disability
Diagnosis
Onset Date
Expected Return to Work Date
Medical Provider Information
Provider Name
Provider Contact
Evaluation
Supporting Documentation Reviewed
Summary of Case Evaluation
Findings
Recommendation
Decision
Decision Status
Approved
Pending
Denied
Evaluator Name
Evaluation Date