For a group disability claim based on multiple sclerosis, Prudential asks the treating neurologist to document the diagnosis on this three-page form. The neurologist gives the years of diagnosis and first symptoms, the date of the latest neurologic exam, the nature of first symptoms and type of MS, how the diagnosis was confirmed, MRI lesion details, and the patient's EDSS from an assessment in the last 12 months.
The treating neurologist completes and signs the assessment, including the GINA acknowledgment and the fraud notice. Prudential identifies the claimant by name and claim number.
Download the current version from the source each time; forms change without notice.
Neurological Assessment of MS Diagnosis
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The neurologist selects one: single demyelinating event, relapsing/remitting, secondary progressive, progressive since onset, or not MS. A separate question records the nature of the first symptoms, such as optic neuritis, spinal cord, brainstem or cerebellar, sensory only or polysymptomatic.
It asks whether the patient has been assessed in the last 12 months and, if so, for the EDSS value. Page 3 provides the Kurtzke Expanded Disability Status Scale definitions so the neurologist can match the patient's function to a step.