Physician’s Statement for Disability Claim
Patient Information
Full Name
Date of Birth
Claim/Policy Number
Address
Phone Number
Physician Information
Physician Name
Specialty
Phone
Address
Medical Information
Diagnosis
Date Symptoms First Appeared
Date Patient First Consulted You
Treatment Provided
Is the Condition Due to Injury or Sickness Related to Employment?
Yes
No
Current Functional Limitations
Disability Information
Date Patient Became Disabled
Date Patient is Expected to Return to Work
Expected Duration of Disability
Additional Comments
Physician’s Certification
Physician’s Signature
Date