When a patient applies for Sun Life short-term disability benefits, Sun Life sends the attending physician this statement with a cover page asking for it back within 5 business days. Pages 2 to 4 cover diagnosis with ICD-10 codes, pregnancy, treatment dates, hospital or house confinement, restrictions and limitations, and when the patient can return to part-time or full-time work.
The attending physician completes each section, 1 through 8, then signs and dates it. The employee completes Sun Life's STD employee statement (GSTDFM-11117) with authorizations and names the treating physician there, and the employer completes the employer statement (GSTDFM-11116).
The cover page tells you the patient has applied for short-term disability benefits and asks for two things within 5 business days: the completed APS, and medical documentation clearly outlining physical or mental restrictions or limitations. Visit notes or test results may be added. It lists fax, email and online return options and asks for the patient name and NTN- claim number on all documents.
Enter the group policy number and the patient's name, date of birth, address, employer, Social Security number, gender and phone number. This section states that the patient is responsible for any costs associated with completing the form. The header on later pages repeats the claimant name, date of birth, policy number and claim control number.
Give the primary diagnosis, including any complications, and any secondary diagnosis, each with an ICD-10 code. Mark whether the condition is a sickness or an accident, with the accident date, and whether the patient had the same or a similar condition before. Answer whether the condition is work related and whether you believe the patient is competent to endorse checks and manage financial affairs.
For a pregnancy claim, enter the expected due date, actual delivery date and delivery type (normal or C-section). List any complications that caused the patient to stop working before the expected delivery or that would extend the normal recovery. Leave it blank only when the claim is not pregnancy related.
Enter the start date of disability and the dates of the first, last and next office visits. Answer whether emergency room care was required, with the hospital, date and phone, and give the type and date of any surgery. Mark whether the patient has been hospital confined, with dates and hospital name, or is house confined, bed confined or ambulatory.
Describe what the patient is unable to do and what the patient should not do, each with From and To dates. The cover page asks for medical documentation that clearly outlines these restrictions or limitations, so attach notes that support each entry. If a mental impairment applies, add the current DSM diagnosis and choose Class 1 (no limitation) through Class 5 (severe limitation).
Indicate the specific date or recovery period after which the patient will be able to sufficiently perform duties, separately for part-time and full-time occupation. Options run from 1 to 2 weeks through 7 to 8 weeks, then 2 months or more, never, or other. The same layout appears on Sun Life's long-term disability statement, GLTDFM-11121.
List up to two other treating physicians with specialty, phone and fax. Then enter your name, tax ID number, address, specialty, phone and fax, and sign and date. 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, printed in Section 9.
Download the current version from the source each time; forms change without notice.
Short-Term Disability Claim Statement – Attending Physician
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
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The cover page asks for the completed statement and supporting medical documentation within 5 business days so Sun Life can make a timely decision on the claim. Send it by fax, email or the online option listed on the cover page, or by mail, with the patient's name and NTN- claim number on every page you send.
Section 1 states that the patient is responsible for any costs associated with the completion of this form. Sun Life does not pay the attending physician for it, so any fee for completing the statement is set by the practice and charged to the patient.
Section 6 asks separately when the patient can return to part-time and to full-time occupation. You can enter a specific date or check a recovery period: 1 to 2, 2 to 3, 3 to 4, 5 to 6, 6 to 7 or 7 to 8 weeks, 2 months or more, never, or other with an explanation.
If a mental impairment applies, Section 5 asks for the current DSM diagnosis and a class: Class 1 no limitation, Class 2 slight, Class 3 moderate, Class 4 marked or Class 5 severe limitation. For a claim driven mainly by a mental health condition, Sun Life's behavioral health provider statement GDIFM-9632 asks for mental status findings, testing and treatment history.