Guardian uses this one-page physician section to get an update on the patient's condition while it reviews a group short term disability claim. The physician confirms when total disability began, treatment dates, whether the patient can do their occupation at its strength level, restrictions, ICD-10 diagnosis, objective findings and treatment plan. Guardian says most decisions are made within 10 business days when information is provided on time.
The employee fills in name, date of birth, plan and claim numbers and signs the authorization at the top of page 1, plus the separate authorization (GG-013843) and fraud statements on the following pages. The attending physician completes items 1 through 14 of the Physician Section and signs.
The employee enters name, date of birth, plan number and claim number, then signs and dates the authorization allowing physicians and others to release medical and non-medical information to Guardian. The authorization is valid up to 24 months, or 12 months in Kansas. Check that the claim number is present before completing your part, since it links the statement to the open claim.
The section opens by saying Guardian is reviewing a short term disability claim and needs an update on the patient's current condition. Enter the date total disability began, the date of first treatment, the date of the most recent evaluation, the frequency of treatment (weekly, monthly or other) and the next appointment date.
Guardian uses this item to tell you which records to send: records for a date range, including diagnostic study and operative reports, the most recent office visit notes, or other items it specifies. Check what is marked on the copy you received and attach those records, since the claims page warns that a statement of disability alone may not be enough.
Mark the strength level of the patient's occupation: sedentary, light, medium, heavy or very heavy. Then answer No, with the date released to return to work, full-time or part-time, or Yes, with the projected return-to-work date, full-time or part-time. Guardian's forms page notes that more medical information may be needed if a disability lasts longer than expected.
Describe the restrictions and limitations that are medically necessary for the disabling condition, with the activities affected and how long each applies. Item 7 has already recorded the strength level of the occupation. In item 9, mark whether the patient's condition has recovered, improved, not changed or retrogressed.
Give the current disabling diagnosis with ICD-10 codes. In item 11, list the current objective findings that support continued total disability, such as exam findings and test results, and attach copies of diagnostic study reports if applicable. Guardian's STD page notes that a physician simply calling a patient disabled may not be sufficient to extend benefits.
Be specific about the treatment plan: surgeries with CPT codes and dates, procedures, medications and therapy. In item 13, answer whether you referred the patient to another physician for treatment or evaluation of the disabling condition, and if so give that physician's name, specialty, address and phone number.
Print the physician's name and specialty, sign and date, and give the address, telephone, fax and email address. The fraud warning printed in the Employee Section covers anyone who files a statement of claim containing materially false information or conceals material facts.
Download the current version from the source each time; forms change without notice.
STD Attending Physician's Statement of Disability
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.
Sources for this guide
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Yes. Guardian's short term disability forms page links the attending physician statement (GG-011981) as a Word (.docx) file, which the page describes as the form the attending physician needs to complete for the claim. A fillable PDF version also exists, with the authorization GG-013843 and state fraud warnings on pages 2 to 4.
Guardian's STD forms page says most decisions are made within 10 business days if information is provided on time. A late or incomplete physician statement can therefore hold up the decision. If the disability lasts longer than expected, Guardian may need more medical information to extend benefits.
Item 6 lets Guardian specify what it needs: records for a stated date range including diagnostic study and operative reports, the most recent office visit notes, or other items it names. Item 11 asks for copies of diagnostic study reports supporting continued total disability, if applicable. Attach what is checked before you send the form.
Yes. The form says documents can be returned electronically at guardianlife.com/forms-and-claims: select Benefits through an employer, choose the plan type, and click Send a document. Mail and fax to Guardian's Group STD Claims unit are also listed at the top of the form.