Sun Life's Customized Disability product is a voluntary worksite income plan, and GVCDFM-3044 is the physician's part of its claim. The nine-page statement has separate paths: a pregnancy section, a physical conditions section covering diagnosis, objective findings, treatment, progress, restrictions and prognosis, and a behavioral health section covering DSM diagnosis, impairment class, treatment history, testing and response to treatment.
The attending physician completes, signs and dates the statement, choosing the physical or behavioral health path. The employee and employer complete separate statements, GVCDFM-3043 and GVCDFM-3042.
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Customized Disability Claim – Attending Physician Statement
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Yes. Physical-condition claims skip it, while behavioral health claims complete it instead of the physical sections. It asks for a current DSM diagnosis, mental impairment class 1 to 5, onset and treatment history, hospital or program stays, chemical dependency, psychological testing, medications and whether the patient can endorse checks.
Both the physical and behavioral health sections ask how long the limitations will apply, with check boxes for an estimated 6 weeks, 8 weeks, 12 weeks or longer. The physical section also asks when the patient should be able to return to work full-time or part-time.