New York Life Group Benefit Solutions (NYL GBS) uses this statement to get the treating physician's account of a group short-term or long-term disability claim. It records the diagnosis with ICD or DSM code, treatment dates, surgery and medications, physical limits across an 8-hour workday, any mental impairment and return-to-work status. The group LTD claim form tells the employer to attach it, along with any other documentation.
The patient or insured fills in the short section at the top of page 1: name, employer, Social Security number, address, group policy number, phone, occupation and date of birth. The physician completes items 1 through 7 and the signature block, which asks for degree, specialty and federal tax ID number.
The patient enters name, employer name, Social Security number, street address, group policy number, telephone number, occupation and date of birth. Check that the group policy number and name match the claim before you start, since the rest of the statement is matched to the claim by these details. The patient's section has no authorization signature; NYL GBS collects a separate Disability Disclosure Authorization with the claim forms.
Give the diagnosis with its ICD or DSM code, the subjective symptoms and the objective findings, attaching current X-rays, EKGs, lab data and clinical findings as applicable. Answer whether symptoms are consistent with the clinical findings, and explain if not. Mark whether the illness is work related. For pregnancy, enter the LMP, EDC and actual delivery date. Copies of current test results back up the objective findings you list here.
Enter the date the patient first visited you for this accident or illness, the date the patient was first unable to work because of it, the frequency and dates of examinations for it, and the date of the last visit. Use month, day and year throughout. Item 2(c) asks for both how often and on which dates you examined the patient for this condition.
Record any hospitalization with from and through dates, any surgery with its date and type, and the name and address of the hospital. Item 3(d), at the top of page 2, lists medications by type and dosage. The section heading covers surgery and prescribed medications, so list both even when treatment is conservative.
For an 8-hour workday, mark how long the patient can climb, balance, stoop, kneel, crouch, crawl, reach, walk, sit and stand: 0 hours, up to 2.5 hours, up to 5.5 hours, or greater than 5.5 hours. Then rate the maximum level (sedentary, light, medium or heavy) for lift, carry, push and pull. If cardiac, choose American Heart Association Class 1 to 4 and enter the blood pressure at the last visit.
For a mental health claim, complete Axis I through Axis V, the current GAF, the highest GAF in the past year, the baseline, and any additional comments. The form states that incomplete information here will delay claim processing, so fill every line that applies rather than referring to attached notes alone.
For both the patient's regular occupation and any other occupation, indicate full-time or part-time capacity and the date (month, day, year), and say when the patient was able to go to work. Remarks gives space for context the grid cannot capture, such as a planned reassessment date or why a return date cannot yet be estimated.
Print the physician's name, degree and specialty, address, telephone number and federal tax ID number, then sign and date. There is no separate certification sentence, but the New York fraud warning and caution on page 1 and the state fraud notices on pages 3 and 4 apply to the statement.
Download the current version from the source each time; forms change without notice.
Physician's Statement (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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The opening instructions ask you to complete all relevant sections as thoroughly as possible and include medical documentation to support your findings. Item 1(c) specifically asks for copies of current X-rays, EKGs, laboratory data and any clinical findings as applicable. Leave out genetic information such as family medical history, which the form excludes under GINA.
The version posted on the NYL GBS forms page is headed GB-608066 Revised 03/2026 on every page. It replaces older copies issued under the Cigna group disability name. The statement is four pages: pages 1 and 2 hold the patient section and items 1 to 7, and pages 3 and 4 are state fraud notices.
Item 4 defines them by weight. Sedentary is 10 lbs. maximum with occasional walking. Light is 20 lbs. maximum and 10 lbs. frequently. Medium is 50 lbs. maximum, 25 lbs. frequently and up to 10 lbs. constantly. Heavy is 100 lbs. maximum, 50 lbs. frequently and 20 lbs. constantly. You pick one level each for lift, carry, push and pull.
Yes. The form says the remaining sections are to be completed by the patient's physician(s), and each statement carries one physician's name, degree, specialty, tax ID and signature. If several physicians treat the disabling condition, each can complete a separate copy covering their own diagnosis, treatment and assessment of limitations.