When a group disability claim rests on a mental health condition, Prudential's Disability Management Services uses this 3-page statement from the attending physician or behavioral health clinician. It asks why disability leave was recommended, for DSM-5 diagnoses with ICD codes, mental status exam findings, limitations and restrictions, treatment and return-to-work status. The questions separate limitations from restrictions and ask whether each is temporary or permanent.
The attending physician or behavioral health clinician answers questions 1 to 6 in Section 2, gives contact details in Section 3 and signs the fraud notice in Section 4. Section 1 holds only the patient's name and claim number, which are repeated at the top of each page.
Enter the patient's first name, middle initial, last name and Prudential claim number. The same identification line appears at the top of pages 2 and 3, so fill it in on every page. Unlike Prudential's general Attending Physician Statement, this form has no employee authorization or signature block.
Answer whether you recommended that this patient be off work. If yes, give the date you first recommended it and explain your rationale for recommending disability leave. This is where the reviewer looks for the clinical reasoning that links the condition to time away from work, so describe it in terms of the patient's symptoms and functioning.
List current psychiatric diagnoses using DSM-5 criteria with the date of onset for each condition cited, and give the ICD code, which the form marks required. Question 3 then asks for the signs and symptoms supporting each diagnosis, split into positive findings on the mental status exam and the patient's subjective symptoms, so the reviewer can see which findings you observed and which the patient reported.
Describe the limitations and restrictions identified on your examination. The form defines limitations as activities the claimant cannot perform because of cognitive deficits or psychiatric symptoms, and restrictions as activities the claimant should not do because participation would be injurious. State whether each is temporary or permanent and how long you expect it to remain in effect.
Record any inpatient hospitalization and any partial hospitalization or intensive outpatient program, with where and when. Give outpatient visit dates (first, last and next) and frequency, current medications with dose and frequency, current side effects and treatment goals. Answer whether there is past psychiatric history or treatment and when, whether another physician or provider referred the patient, and list other treating physicians or behavioral health providers with specialty and phone.
Answer whether a return-to-work date has been discussed with the patient and give the target date. Mark whether the patient has improved, regressed or not changed. If the patient is able to work now with accommodations or modifications, list them, and say whether the patient would benefit from vocational rehabilitation services or assistance.
Enter your name, primary telephone and fax numbers, office address and specialty. On page 3, read the fraud notice, which warns that knowingly submitting incomplete, false or misleading information on a claim is a fraudulent insurance act, then sign and date to certify that the statements are true.
Download the current version from the source each time; forms change without notice.
Attending Physician Behavioral Health Statement
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Sources for this guide
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Limitations are activities the claimant is unable to perform because of a cognitive deficit or psychiatric symptom. Restrictions are activities the claimant should not do because participation would be injurious to a person with those symptoms. Question 4 also asks whether each is temporary or permanent and how long you expect it to remain in effect.
Yes. Question 2 asks you to list current psychiatric diagnoses using DSM-5 criteria with the date of onset for each, and the form states that the ICD code is required. Question 3 then asks for the signs and symptoms supporting each diagnosis: positive findings on mental status exam and the patient's subjective symptoms.
Section 2 is headed 'To Be Completed by Attending Physician/Behavioral Health Clinician', so either the attending physician or the treating behavioral health clinician can answer it. Section 3 records the clinician's name, specialty and office contact details, and the form is signed under the fraud notice on page 3.
Question 5 asks about inpatient hospitalizations and partial or intensive outpatient programs (where and when), outpatient visit dates and frequency, current medications with dose and frequency, side effects and treatment goals. It also asks about past psychiatric history, whether another provider referred the patient, and other treating physicians or behavioral health providers.