A Guardian group life insured who becomes totally disabled can apply to have premiums waived, and GG-117 is the attending physician's statement for that request. The physician documents ICD-10 diagnoses, condition history, treatment program, progress and medical stability, whether the patient can do any part-time or full-time sedentary or light work, physical capacities, cardiac and psychiatric impairment, and competency.
The employee completes the Employee Section and signs the authorization. The attending physician completes the Physician Section, items 1 to 33, and signs with degree, specialty and tax ID.
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Attending Physician's Statement for Waiver of Premium
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The heading of the Physician Section states that the patient is responsible for the cost of completing the form. Guardian also asks the physician to attach pertinent medical records such as office notes, test results, discharge summaries, operative and consultation reports, which speeds processing.
Item 23 covers an 8-hour workday: lift and carry and push and pull in pound ranges, total hours of sitting, standing and walking with positional changes, how often the patient can bend, reach out, reach above and drive, dominant hand, other restrictions and their duration.