For a stroke claim under Guardian group critical illness insurance, Guardian asks the physician to record the patient's functional outcome on the Modified Rankin Scale using this one-page form. The physician checks the score from 0, no symptoms, to 6, death, enters the total and signs; the form travels with the main critical illness claim so Guardian can judge the stroke's lasting effect.
The employee section at the top identifies the employee, plan and claim numbers, patient and physician. The physician completes the Physician Section score and signs and dates it.
Download the current version from the source each time; forms change without notice.
Modified Rankin Scale Form – Critical Illness
If your copy of the form is a fillable PDF, upload it 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.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Score 0 means no symptoms at all. Score 1 means no significant disability despite symptoms, with the patient able to carry out all usual duties and activities. The physician records one score and writes it as the total, from 0 to 6.
It is a single scoring page that accompanies the Group Critical Illness Claim Form, GG-016218, rather than a full narrative statement. Guardian's critical illness claim form has no physician section of its own, so supporting medical records should be sent with the claim as Guardian requests.