The Hartford sends this two-page initial statement for a new group short-term or long-term disability or leave claim, with the patient's claim ID. The provider documents the condition, onset, first day out of work, projected return date, ICD-10 codes, treatment plan, medications, level of functionality and diagnostic tests. The Hartford does not post the form publicly.
The treating provider completes the whole form and signs it with specialty, EIN and license number. There is no employee or employer section on the statement.
Download the current version from the source each time; forms change without notice.
Attending Physician's Statement – Initial
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LC-7135 states that the patient is responsible for any expense related to completing the form. Any fee the practice charges for completing it is therefore the patient's responsibility, not The Hartford's. The form is completed by the treating provider.
The Hartford does not post its group disability forms publicly; it sends the statement for each claim with the claim ID. Copies posted on employer websites are pre-printed with that employer's group policy number, so they serve only as a reference.
Page 2 asks the provider to address the patient's full range of abilities: sitting, standing and walking hours, driving, climbing, bending, lifting and carrying, and hand and reach functions, rated continuous, frequent, occasional or never. The Hartford concludes there are no restrictions unless they are specified.