Guardian sends this questionnaire to the treating provider when a long-term disability claim depends on the patient being immunocompromised. The provider identifies the type of diagnosis, contributing conditions, immunosuppressive medications and whether they are permanent, planned or completed procedures such as transplant, required precautions, whether the condition is stable, work limitations, whether working from home is possible and the expected release date.
The treating provider answers all twelve questions and signs with printed name and specialty. The patient's name, claim number and birth date identify the file.
Download the current version from the source each time; forms change without notice.
Immunocompromised Questionnaire
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Question 8 asks whether, from an immunocompromised perspective, there are limitations or restrictions affecting the patient's ability to do any work. The provider lists them or confirms there are none from an immune perspective, then answers whether remote work is possible and when a return to work is expected.
Yes. Question 5 asks whether a procedure such as a transplant is planned, with the scheduled date, and question 6 asks whether a procedure has been completed and when. Question 7 asks what precautions the claimant must take.