Guardian's group long term disability claim packet ends with this Section 3, where the physician who treated the claimant when they stopped or cut back work documents the condition. It covers diagnosis with ICD codes, treatment and hospital stays, physical, psychiatric and cardiac impairment, and the expected return to work. Guardian reviews it together with the claimant's and employer's statements to decide the LTD claim.
The claimant completes and signs the patient authorization at the top of Section 3, and the physician who first treated them when they stopped working or reduced their hours completes the rest. Section 1 of the packet belongs to the claimant and Section 2 to the employer or planholder.
The claimant enters their name, date of birth, address, employer or planholder name and group policy number, then signs and dates. The authorization lets physicians, hospitals, pharmacies and others give Guardian information about the claimant's condition, which can include HIV infection, mental illness or alcohol or drug use. It is valid for up to 24 months (12 months in Kansas), and the heading notes that the patient pays for completing the form.
Check whether the condition is the result of illness, injury or pregnancy, and whether it is due to a work-related illness or injury. For pregnancy, give the LMP date and the delivery date, marked expected or actual, then the type of delivery (vaginal or C-section) and whether it was a single or multiple birth.
Enter the primary diagnosis and any secondary diagnoses, each with its ICD-9/10 code. Describe the subjective symptoms and the physical examination findings. For test results, list each test with its date and result, or enclose the reports instead. Enclosing the reports also answers the boxed request later in the form for diagnostic test results.
Give the date of onset, the date you first treated the patient for this condition, the most recent and next visit dates, and visit frequency (weekly, monthly or other). Note any referral to or from another physician with contact details, and describe the treatment plan, including medication, therapy, counseling and rehab. Record any surgery with date, procedure and CPT code, hospital admission and discharge dates, progress (recovered, improved, unchanged, retrogressed) and whether the patient is ambulatory or bed, house, hospital or nursing home confined.
State whether you advised the patient to reduce work hours, cease work or work light duty, with the date for each. Then rate what the patient can do in an 8-hour work day: lift/carry and push/pull in pound ranges from 1-10 to 76+, hours of sitting, standing, walking and alternating sit/stand, and how often they can bend or stoop, reach and drive. Add the dominant hand, other restrictions and how long the restrictions will last.
If applicable, check one psychiatric level, from inadequate information to make an assessment through inability to function in almost all areas, and give the current GAF and the highest GAF in the past year. Say whether the patient is competent to endorse checks and direct the use of the proceeds. For cardiac impairment, check Class 1 to Class 4 and supply height, weight, blood pressure and ejection fraction with its date.
Answer whether the patient has some capacity for work. If yes, give the date and whether it is full-time or part-time. If no, give the date you anticipate the patient will have capacity for work and whether that will be full-time or part-time, or check never. A boxed note below asks you to attach pertinent medical records such as progress notes, test results, discharge summaries, operative and consultation reports.
Enter your name, degree, specialty, address, telephone and fax numbers and Tax ID number, and use Remarks for anything the fields did not capture. Read the fraud notice, including the New York statement, then sign and date. The signature line reads 'Signature of Physician (no stamp)', so sign it yourself rather than with a stamp.
Download the current version from the source each time; forms change without notice.
Application for Long Term Disability Income Benefits – Section 3 Attending Physician's Statement
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Sources for this guide
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Guardian's instructions say the attending physician section goes to the physician who first treated the claimant at the time they stopped working or reduced their work hours. The claimant completes and signs the patient authorization at the top of Section 3, and the employer or planholder completes Section 2 of the packet.
The patient authorization printed at the start of Section 3 says the patient is responsible for the cost of completing the form. The packet lists no Guardian fee schedule or billing code for the statement, so any charge for completing it falls to the patient rather than to Guardian.
The statement asks for pertinent medical records, including but not limited to progress notes, diagnostic test results, discharge summaries, operative reports, consultation reports and a mental status exam if applicable. Guardian says this helps expedite claim processing and reduces additional requests and follow-up. Test results can also be listed on the form itself or enclosed.
Yes. The packet is a fillable PDF, and Guardian's instructions suggest completing it on screen, printing and signing it, saving the completed file and then sending it through the Secure Channel claim submission. Guardian's group LTD page also links to online claim filing and to Secure Channel for sending documents.