Sun Life sends this statement to the psychiatrist, psychologist or other behavioral health provider treating a patient whose short-term or long-term disability claim rests on a mental health condition. It asks for current DSM diagnoses, treatment history, medications, mental status findings, functional limits and return-to-work planning. The cover page asks for it, with supporting records, within 5 business days so Sun Life can make a timely decision.
The behavioral health treating provider completes every section, from patient information through Section 3, and signs with an original signature. The employee files Sun Life's separate claim statement and authorizations, and the employer completes its own statement.
The cover page explains that the patient has applied for disability benefits, which may provide income replacement and/or job protection, and asks for the completed statement plus medical documentation outlining any restrictions or limitations within 5 business days. It lists fax, email and online return options and asks for the patient name and claim number (NTN-) on all documents.
Check Short-Term Disability or Long-Term Disability. Enter the group policy number, the patient's name, sex, address, Social Security number, date of birth, phone and employer (parent company name). The diagnosis lines below are marked Use current DSM, with room for up to three diagnoses. Section 1 also states that the patient is responsible for any costs of completing the form.
Give the date of disability, date of first signs of illness, date of first exam and date of the recent exam, and mark visit frequency as weekly, monthly or other. Answer whether the patient has ever had a psychiatric hospitalization, partial hospitalization or intensive outpatient treatment, and if so give the facility, admission and discharge dates.
List current medications, any recent medication changes and the reason for each change, the treatment goals and estimated duration of treatment. Describe the patient's initial reason for seeking treatment, how and when symptoms first appeared and how they progressed, and the current symptoms. Say whether quantitative evaluations of functional impairment were performed, and if so list the testing and send copies with the raw data.
Answer whether the patient is appropriately groomed and whether there is impairment in concentration, thought process or memory, explaining each. Say whether the patient can manage financial affairs and, if so, whether you believe the patient is competent to endorse checks. Then check the boxes that describe behavior, speech and mood, using Other for anything the options do not cover.
Explain any activities the patient is unable to perform because of cognitive difficulties or psychiatric symptoms, and any the patient should not do because they would worsen the condition. Answer whether the condition was precipitated by a workplace situation and whether problems relate to alcohol or drug abuse, with details. State whether return to work is part of the treatment plan, the estimated date, part-time or full-time, and how you will judge readiness.
Specify other factors that may have precipitated the condition or could influence recovery and return to work. The form's examples include family history, effects of physical illness, psychological and educational history, inability to tolerate medications, legal or licensing difficulties, financial difficulties and occupational issues. Then answer whether the patient has had symptoms of the same, similar or another mental or emotional disorder before.
Enter the treating provider's name, tax ID number, address, specialty, phone and fax, then sign and date. The form states that an original signature is required, and signing certifies that the statements are true and complete and that you have read, or had read to you, the fraud warning for your state in Section 4.
Download the current version from the source each time; forms change without notice.
Disability Claim Statement – Behavioral Health Treating Provider 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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The provider treating the patient's mental health condition, such as a psychiatrist, psychologist or other behavioral health clinician. The form is addressed to the Treating Provider, who completes each section, signs with an original signature and gives a tax ID and specialty. It sits alongside Sun Life's attending physician statements for STD (GSTDFM-11118) and LTD (GLTDFM-11121).
The cover page asks for the completed statement and medical documentation outlining any physical or mental restrictions or limitations within 5 business days. Office visit notes or test results may be included. Put the patient's name and the claim number, which starts with NTN-, on every document so it can be matched to the claim.
Yes. The form opens with a choice of Short-Term Disability or Long-Term Disability, and Sun Life's forms library lists it under both STD and LTD. The instructions give one mailing address and email for both, with a separate fax line for each claim type.
It asks whether the patient is appropriately groomed, whether there is impairment in concentration, thought process or memory, and whether the patient can manage financial affairs and endorse checks. Checkboxes cover behavior (normal, agitated, irritable, belligerent), speech (appropriate, tangential, rapid or pressured, delayed, monotone) and mood (appropriate, depressed, anxious, hostile, euphoric, agitated).