Empire Life's Group Forms Library lists this form as the Attending Physician's Statement for short- and long-term disability; it is the industry Initial Disability Insurance Medical Statement, June 2025 version. Empire's claimant statement tells employees that the physician treating their current injury or sickness must complete an attending physician's statement for a disability claim.
The employee completes Section 1 (patient information, medications and consent), and the attending physician or other medical provider completes Section 2, the Medical Statement. The employee and employer also complete Empire's own claimant and employer statements.
Download the current version from the source each time; forms change without notice.
Initial Disability Insurance Medical Statement
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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Empire's Group Forms Library links the industry Initial Disability Insurance Medical Statement under the title Attending Physician's Statement, Short/Long Term Disability, for group plan members and administrators. The PDF is the standard June 2025 version, without Empire-specific questions, and Empire also keeps a French group forms library.
The employee. Empire's Claimant's Statement for Disability Benefits says the employee is responsible for paying any fee the physician charges for completing the form, and the medical statement itself states that the patient is responsible for any fees related to its completion.