Physician Statement for Disability Insurance
Patient Information
Full Name
Date of Birth
Address
Phone Number
Physician Information
Physician Name
Specialty
Practice Name/Address
Phone
Medical Diagnosis
Primary Diagnosis
Other Relevant Diagnoses
Medical History
Date Symptoms Began
Date of First Visit
Date of Last Visit
Frequency of Visits
Summary of Treatment Provided
Functional Limitations
Describe Patient’s Limitations
Ability to Perform Usual Occupation
Ability to Perform Other Work
Prognosis
Estimated Duration of Impairment
Is Patient Expected to Recover?
Recommended Restrictions
Physician Certification
Physician Signature
Date