Prudential's group disability team sends this two-page questionnaire to the ophthalmologist or optometrist when a disability claim involves vision. The physician records best-corrected distance and near acuity, peripheral and central fields, hemianopsia, muscle function, depth and color perception, intraocular pressure and fundus findings, then the diagnosis with ICD codes and how often the patient can perform visual work tasks in an 8-hour day.
The treating eye care physician completes all three sections and signs with specialty. Prudential enters the claimant's name and claim number; the patient completes nothing on this form.
Download the current version from the source each time; forms change without notice.
Prudential Visual Capacity Questionnaire
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The treating ophthalmologist or optometrist completes it, since it asks for exam findings such as best-corrected acuity, visual fields, intraocular pressure and fundus exam. The physician signs the fraud certification and adds their specialty and printed name.
Yes. Item 5 records color perception as normal or limited, and whether a deficit is acquired, by eye. Discriminating colors and textures is also one of the workday tasks the physician rates from never to constantly.