Prudential Disability Management Services uses this 2-page form to learn what a group disability claimant can do at work, so the employer can review return to work or modified duty. The health care provider completes it at every office visit, recording a full duty release date or a return date with restrictions. The form tells the provider not to disclose the patient's medical condition.
The employee's health care provider completes the whole form at each office visit: Section 2 on work capacity and restrictions, and Section 3 with provider details and a signature under the fraud notice. The claimant's name and claim number go at the top of each page.
Download the current version from the source each time; forms change without notice.
Employer Review Capability Form
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No. The form states in capital letters that the patient's medical condition should not be disclosed when completing it, because it supports the employer's review of return to work or modified duty. Describe only the restrictions and limitations, how long they last, and the next office visit date.
The form is headed 'To Be Completed by the Employee's Health Care Provider at each Office Visit.' Prudential asks that it be faxed within 24 hours after each visit, so updated restrictions, the estimated full duty release date and the next visit date reach the claim promptly.
The form's footnote says expired restrictions and limitations equate to a full duty release as of the end date. If the patient still needs restrictions, record a later Restrictions Needed Through date on the form completed at the next office visit.