Disability Claim Attending Physician’s Statement
Patient Information
Patient Name
Date of Birth
Policy/Certificate Number
Claim Number
Medical Information
Diagnosis (including ICD code)
Date of First Visit
Date of Last Visit
Subjective Symptoms
Objective Findings
Treatment Plan
Medications
Disability Assessment
Period Totally Disabled (dates)
Current Restrictions/Limitations
Prognosis for Recovery
Physician Information
Physician Name
Specialty
Address
Phone Number
Fax Number
Physician Signature
Date