For a group disability claim based on a heart condition, Prudential asks the treating cardiologist or physician to complete this three-page cardiac statement. It covers visit history, diagnoses with ICD codes, medications and stability, American Heart Association functional class, cardiac rehab, blood pressure, ejection fraction, stress test protocol and METs achieved, the treatment plan, functional limits and a return-to-work certification.
The attending physician completes Section 1 and signs the fraud certification with specialty. Prudential identifies the claimant by name and claim number.
Download the current version from the source each time; forms change without notice.
Attending Physician Statement – Cardiac
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It asks for the most recent blood pressure, the ejection fraction with its date, and whether a stress test was done, when, which protocol such as nuclear or treadmill, and the MET level achieved, plus whether there was evidence of heart disease.
Page 3 asks whether the patient is limited in sitting, standing, walking and lifting, how long they can sit or stand before adjusting, how far and long they can walk before stopping, the maximum weight they can lift, and what accommodations might help.