Prudential sends this two-page capacity questionnaire to the treating physician during a group disability claim to pin down what the patient can do now. The physician states whether there is full-time or part-time transitional work capacity, estimates a full-time return date, grades 19 physical activities from never to constantly, and lists restrictions, limitations and accommodations that could increase work capacity.
The treating physician completes Sections 2 and 3 and signs the certification with specialty. Prudential fills in the claimant's name and claim number, which should appear at the top of each page.
Download the current version from the source each time; forms change without notice.
Capacity Questionnaire
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Prudential asks for a response within two weeks of receiving the questionnaire. Without a reply, it states that its opinion will be based on the information already available in the claim file, so a late response may mean the claim is decided without it.
It gives examples of accommodative measures that may raise work capacity: adaptive devices such as voice recognition software, a foot-controlled mouse or lifting devices, working from home, scheduling flexibility and breaks during the workday, along with changes to the workplace, equipment or how work is done.