Guardian sends this condition-specific questionnaire to the treating provider, often a rheumatologist or primary care physician, when a short-term disability claim is based on lupus. The provider indicates the presence or absence of eleven lupus features with supporting lab results, whether other conditions have been ruled out, the treatment plan, effects on daily activities, assistive devices, medications and whether lupus limits the patient's ability for any work.
The treating provider completes the questionnaire and signs with printed name and specialty. The patient's name and claim number go at the top of each page.
Download the current version from the source each time; forms change without notice.
Lupus Form (Group STD Lupus Assessment Form)
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The provider answers whether, from a lupus perspective, there are limitations or restrictions that affect the patient's ability to do any work. If yes, the restrictions are listed; if no, the provider checks that there are none from a lupus perspective. Last and next visit dates follow.
Yes. Items 16 and 17 ask for current medications and whether they are effective, and if not, what alternative treatments are being used. Item 13 asks for the current treatment plan and items 14 and 15 cover daily living activities and assistive devices.