Prudential sends this short oncology statement to the treating physician to evaluate a group disability claim based on cancer. Eleven questions cover the type and stage, any metastasis, the date of disability, hospitalization, the treatment plan with start, frequency and end dates and whether it is palliative, surgery, tolerance and complications, current symptoms, recent tests, prognosis or remission, and the return-to-work plan.
The treating oncologist or physician answers all 11 questions and signs with specialty. Prudential fills in the claimant's name and claim number.
Download the current version from the source each time; forms change without notice.
Attending Physician Statement – Cancer
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The instructions ask the physician to respond to the questions and return the form to Prudential's office within two weeks, by fax to the number listed in the header. The claimant's name and claim number appear at the top of both pages.
Yes. Question 7 asks how the patient is tolerating treatment and whether there have been complications, and question 8 asks for current symptoms and impairments. Together they show how treatment affects the patient's ability to work.