Treating physician updates diagnosis, treatment and restrictions for an ongoing New York Life individual disability claim.
- Completed by
- Treating physician
- Issued by
- New York Life Insurance Company
- Format
- Fillable PDF
- Language
- English
New York Life 25027: Physician Statement, New IDI Claim
When a patient files a new claim under a New York Life individual disability insurance policy, the treating physician completes form 25027 to document the medical basis. Across Steps 2 to 10 the physician records each diagnosis impacting function, history, rehabilitation and return-to-work status, functional, visual and mental capacity, and the exact periods the patient could not work or could do some work.
Who completes it
The insured completes Step 1 with name, occupation, policy and claim numbers. The attending physician completes Steps 2 through 9 and signs the Step 10 declaration with specialty, license number, tax ID and a stamp or seal.
Submitting and payment
- How to submit it
- Step 11 of the form lists mail, fax and email to New York Life Individual Disability Insurance; the physician can use any of the three.
- Who pays
- The form sets no fee and does not say who pays for the physician's statement.
Good to know
- Step 2 has room for three diagnoses, each with code, symptoms, onset date, treatment, medications and the pharmacy used, plus current status from ambulatory to hospital-confined and whether the patient can drive.
- Step 5 rates sitting, standing, walking, driving, bending, reaching and computer use per eight-hour day, and asks for a physical impairment class and, where relevant, New York Heart Association classes.
- Step 7 asks whether the patient can manage property and endorse checks, whether psychological testing was done, and whether a guardian or power of attorney is in place.
- Edition 07/2022. Companion forms are 25019 Claimant's Statement, 25018 Claimant's Occupational Duties Form and 25023 Provider Specific Authorization to Release Medical Records.
Get the official form
Download the current version from the source each time; forms change without notice.
Physician's Statement for New Claim – Individual Disability Insurance
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.
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Frequently asked questions
What does New York Life form 25027 ask about mental capacity?
Step 7 rates five abilities, such as following detailed instructions and sustaining attention, from None to Extreme or Not Ratable, on a regular and sustained basis. The physician then picks a mental or nervous impairment class from 1 to 5 and lists duties the patient cannot perform because of it.
Does signing form 25027 commit the physician to future updates?
The Step 10 declaration states that the physician understands periodic updates, including copies of medical records when requested, will be required if the claim continues. Ongoing claims use the shorter Physician's Statement for Continuing Claim, form 25033.
What dates does Step 8 of form 25027 require?
Based on objective findings and medical opinion, Step 8 asks for the from and to dates the patient was unable to work and, separately, the dates the patient was able to perform some work. The physician then lists all current work and personal restrictions, or writes NONE.