Employees covered by standalone Mutual of Omaha or United of Omaha short-term disability use this 15-page claim packet. The attending physician completes Section 3 with diagnoses and ICD-10 codes, treatment dates, physical and mental limitations, the period of continuous disability and the expected return to work. The claim is not considered complete until the physician, the employee and the employer have each signed their section.
The attending physician completes and signs Section 3. The employee completes Section 1 and both authorizations, and the employer completes and signs Section 2.
The employee gives the employer's name, the group ID number (eight characters beginning with G000), job title, weekly hours, contact details, height, weight and dominant hand. The guide defines the date of disability as the first day absent because of the condition and the date first treated as the first date care was sought. The employee lists every treating physician and hospital, other income sources and a tax withholding choice, then signs; the form is not complete without that signature.
The employee or a legal representative signs both authorizations. The first lets physicians, hospitals, insurers, employers and agencies release medical, insurance, Social Security, workers' compensation and earnings records to Mutual of Omaha, and it may include mental health, substance use and HIV information unless state law restricts it. Medical records may be needed for a decision, so the guide asks employees to send the signed authorizations with the claim to avoid delays.
The employer reports group ID, class, gross weekly earnings, salary effective date, weekly hours and eligibility for long-term disability, state disability, paid family or medical leave and group life. It records the tax treatment of premium, sick leave, vacation and salary continuation with dates, hire and coverage dates, any prior carrier, the job's strength demand from sedentary to very heavy, the last day at work and whether part-time or modified duty could be accommodated. The employer attaches the job description and signs.
Enter the employer name, group ID and the patient's details, then diagnoses with ICD-10 codes, symptoms and onset date, and the initial, last and next treatment dates. Mark whether the disability is work related and due to accident/injury or sickness, and list surgical codes and procedures with dates. For pregnancy, give the last menstrual period and the expected and actual delivery dates and types. Then answer whether the patient had emergency room care, another treating physician, hospital confinement or outpatient surgery, with dates and facility names.
Indicate how often per day the patient can lift and carry in weight bands from 1 to 5 pounds up to over 100 pounds, using n for never, o for occasional, f for frequent and c for constant. Then give the longest single time the patient can perform activities such as sitting, standing, walking, kneeling, bending, squatting and stooping, plus total time on feet, right and left finger dexterity and reaching below and above shoulder level.
Check the patient's current ability to adapt to job situations as unlimited, somewhat limited, markedly limited or unable to perform. Items include following work rules, repetitive work, keeping a constant pace, attention and concentration, complex instructions, relating to coworkers and supervisors, dealing with the public, judgment and decisions, directing others and working alone. Then describe which functions of the patient's own occupation they cannot perform, with your rationale, and the functional restrictions in place.
State when the patient should return to their prior level of functioning and whether you recommend vocational rehabilitation. Give the dates of continuous disability and when the patient should be able to work full-time or part-time, on a specific date or within 1 month, 1 to 3 months, 3 to 6 months or another period, plus the treatment plan. Finish with your printed name, specialty and degrees, Tax Identification Number, contact details and an office contact, then sign and date.
Download the current version from the source each time; forms change without notice.
Group Short-Term Disability Claim Form – Section 3 Attending Physician's Statement
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Sources for this guide
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Section 3, the Attending Physician's Statement. It asks for diagnoses with ICD-10 codes, symptoms, treatment dates, surgical codes, pregnancy details, emergency and hospital care, lifting and carrying frequencies, mental limitations, the dates of continuous disability and when the patient should be able to work. The form is complete only once the physician signs it.
Section 3 asks how often per day the patient can lift and carry in weight bands from 1 to 5 pounds up to over 100 pounds, using n for never, o for occasional, f for frequent and c for constant. It then asks for the longest single duration for sitting, standing, walking and other activities.
Section 3 lets the physician say the patient should be able to work full-time or part-time on a specific date or, if a date is unavailable, within 1 month, 1 to 3 months, 3 to 6 months or another specified period. It also asks for the treatment plan for return to work or prior level of function.
Yes. Mutual of Omaha posts a Spanish edition of the standalone short-term disability claim form alongside the English version. Group claim forms are listed on Mutual of Omaha's forms page after choosing the plan member (employee) option and a state.