Try for free

New York Life GBS Medical Request Form (Disability)

New York Life Group Benefit Solutions sends this one-page request when it is evaluating a patient's group disability claim and needs the treating physician's current view. The physician lists the diagnoses with ICD codes, the treatment plan, medications and restrictions at work and at home, then states whether the patient could return to work if accommodations were made, and if not, when.

Who completes it

The treating physician answers every question on the page and signs it, adding degree, specialty and federal tax ID. The claimant's name and birth date identify the patient; there is no patient or employer section.

Submitting and payment

How to submit it
The physician returns the completed page to New York Life Group Benefit Solutions by fax, using the number printed at the top of the form, with copies of supporting reports attached.
Who pays
The form sets no fee and does not say who pays for the physician's answers.

Good to know

  • The form opens with a GINA notice: do not include genetic information, which covers family medical history, genetic test results and genetic services for the patient or relatives.
  • Attach office notes, consultations and test results; the form warns that leaving out supporting reports may delay the claim decision.
  • The treatment plan section asks specifically about physical therapy, surgery, specialty referral, electrodiagnostic studies and imaging, each listed with supporting documentation.
  • Restrictions are split into two boxes, at work and at home (activities of daily living), and only medications related to the impairment or affecting return to work are requested.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Request Form

Official pagePDF

How this list is checked

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.

Frequently asked questions

Why does the New York Life Medical Request Form say not to send genetic information?

The Genetic Information Nondiscrimination Act bars covered entities from requesting genetic information, so the form asks the physician to leave it out. That includes family medical history, genetic test results for the patient or a family member, use of genetic services, and genetic information about a fetus or embryo.

What return-to-work answers does the form need?

The physician states whether the patient could return to work now if accommodations were made for the listed restrictions. If not, the form asks why and for a best estimate of the return date, given separately for a return with restrictions and a return without restrictions.

Which companies use this New York Life Medical Request Form?

It is a New York Life Group Benefit Solutions form. The footer explains that these group products are provided by New York Life Insurance and Annuity Corporation, Life Insurance Company of North America and New York Life Group Insurance Company of NY, all subsidiaries of New York Life.