While a Guardian short-term disability claim is open, the attending physician uses NRO-015735 to report progress. The statement covers the current diagnosis and codes, treatment program with CPT codes, visit dates, other treating providers, maximum medical improvement, whether and when the patient was released to work, functional limits in a workday, mental and cognitive limits, competency and cardiac class.
The employee completes the Employee Section and signs the authorization. The attending physician completes the Physician Section, items 1 to 30, and signs personally.
Download the current version from the source each time; forms change without notice.
STD Ongoing Physician's Statement of Disability
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No. The signature line reads Signature of Physician with the note no stamp. The fraud notice above it states that knowingly filing false or misleading information carries criminal and civil penalties and that this includes the attending physician portions of the form.
Yes. Item 12 asks whether the patient is a candidate for vocational rehabilitation. Items 8 and 11 ask whether maximum medical improvement has been reached, with a date, and when a release to work is expected, part-time, full-time or never.