Prudential's Disability Management Services uses this 2-page statement to evaluate group short term and long term disability claims. The attending physician gives ICD-coded diagnoses, the date significant loss of function occurred, the return-to-work plan, medical obstacles to returning and the treatment history. A Spanish edition is published alongside the English form on Prudential's resource center for physicians.
The employee completes Section 1 (employer, the required control number, claim number and identifiers) and signs the release authorization. The attending physician completes Sections 2 and 3 and signs the fraud notice in Section 4.
The employee enters the employer's name, the control number (marked required), name, claim number, Social Security number, date of birth and gender. Signing authorizes the physician named on the form to release the requested information for claim processing. The section also states that the employee is responsible for completing the form without expense to Prudential.
Enter the clinical diagnosis as a primary and up to two secondary diagnoses, each with an ICD code, which the form marks required. For pregnancy, give the EDC and the actual delivery date. Then record the date when significant loss of function occurred. These fields sit at the top of Section 2, before the return-to-work questions, and the ICD requirement applies to each diagnosis line you use.
Answer whether the claimant is competent to endorse checks and direct the use of proceeds. Give the return-to-work target date and mark full-time, part-time or with limitations (functions lost), then describe the return-to-work plan with corresponding limitations. Describe any medical obstacles to returning, the nature of the medical impairment (loss of function), and any non-medical factors, such as interpersonal, financial or family issues, that significantly affect functional abilities.
Answer yes or no for maternity, motor vehicle accident, work related, accident and sickness, and for a motor vehicle accident give the state where it occurred. List other treating physicians or consultants with first and last name, specialty and telephone number. The list continues at the top of page 2 if more providers are involved.
Page 2 repeats the employee's name, claim number, date of birth and Social Security number. Give the date of any surgical procedure and describe relevant tests and surgical procedures specifically, then current medications, treatment and prognosis. Enter the first, last and next visit dates, and say whether the claimant was hospital confined, with from and to dates and the hospital's name and address.
Enter your first name, middle initial and last name, primary telephone and fax numbers, office address with suite, city, state and ZIP code, and specialty. This block identifies the attending physician who signs the statement; other treating physicians and consultants belong in the lists in Section 2, not here.
The notice warns that knowingly submitting incomplete, false, deceptive or misleading information on a claim is a fraudulent insurance act that may be prosecuted under state law, and that an insurer may deny benefits if false material information is given. Sign and date to certify that you have read it and that the statements are true.
Download the current version from the source each time; forms change without notice.
Group Disability Insurance Attending Physician Statement
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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Yes. Prudential publishes GL.2003.251 (S), titled Declaración del médico de cabecera, Edition 11/2015. It covers the same ground over 3 pages instead of 2, from the employee information and authorization to the physician's diagnosis, treatment, return-to-work and contact questions.
Yes. The clinical diagnosis block prints 'ICD Code is Required' beside the primary and two secondary diagnosis lines. Give the code with each diagnosis, then describe relevant tests and surgical procedures, which the form asks you to be specific about, and the date of any surgical procedure.
Section 1 states that the employee is responsible for the completion of this form without expense to Prudential. Prudential lists no fee or billing code for the statement, so any charge for completing it is between the practice and the employee rather than billed to Prudential.
Section 2 asks whether any non-medical factors have a significant impact on functional abilities and gives interpersonal, financial and family factors as examples. The question sits beside the ones on medical obstacles to return to work and the nature of the medical impairment, which the form describes as loss of function.