The Standard's long term disability claim packet runs 15 pages, and the Attending Physician's Statement on pages 10 and 11 is the clinician's part. Part B asks for diagnoses with ICD codes, vitals, history and hospitalization, physical, mental and cognitive limitations, treatment, prognosis and return-to-work timing. The Standard says it needs documentation of functional impairment to decide whether the condition is disabling.
The patient completes Part A with identifying details, employer, group policy number and return-to-work dates. The physician completes Part B, items 1 through 6, and each physician seen for the disability completes a separate statement, while the patient and employer fill in their own statements elsewhere in the packet.
The patient enters full name, Social Security number, other names used, address, phone, birthdate, patient number, occupation, employer and group policy number, plus the date of any return to work or expected return. Check that it is filled in before you begin Part B, because Part A ties your statement to the right claim.
List the primary and secondary diagnoses with ICD codes and any other related diagnoses, then symptoms, height, weight, blood pressure in each arm, radial pulse and dominant hand. Answer whether the condition is primarily related to the patient's employment, a mental disorder, an alcohol or drug condition, or pregnancy. For pregnancy, add expected and actual delivery dates, gravida and para, complications and delivery type.
Note who referred the patient, whether the patient had the same or a similar condition before, and whether other conditions contributed. Give the date the patient first consulted you for this condition and for any condition, dates of subsequent treatment and the most recent visit. For hospitalization, mark inpatient or outpatient and give admission and discharge dates, admitting and discharge diagnoses and the hospital name.
Give the date you recommended the patient stop working and why. Describe the patient's physical, mental and cognitive limitations and work activity limitations, and how long from today they will impair the patient. Answer whether the patient is competent to manage insurance benefits and, if not, whether the patient can appoint someone to help. Part B's opening says The Standard needs documentation of functional impairment.
Describe the planned course of treatment with expected duration, surgeries and therapy, and list medications with dosage, frequency and prescription dates. Name other treating or referring physicians. Suggest reasonable work or job site modifications the employer could make. Mark any complicating factors: malingering, a significant emotional or behavioral disorder, exaggeration or inconsistent findings, dependence on drugs or medication, or other.
Describe the patient's condition since onset as recovered, improved, unchanged or regressed. Say when you expect a fundamental or marked change (never, expected to regress, or expected to improve, with a date or a follow-up in months), and when the patient can return to work, either as an anticipated date or unable to determine with the reason and a follow-up interval. Use Remarks for anything else.
Sign and date, then print your name, specialty, address, taxpayer ID number, phone and fax. The acknowledgement certifies that the answers are complete and true to the best of your knowledge and belief and that you have read the applicable fraud notice that follows the statement.
Download the current version from the source each time; forms change without notice.
Long Term Disability Insurance Attending Physician's Statement (Long Term Disability Benefits Claim Packet)
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The packet instructions say that if the patient has seen more than one physician for the disability, a statement should be completed by each physician, and extra forms are available from the employer. Each physician completes Part B separately, and lists other treating or referring physicians in item 4.
Part B asks for laboratory data and results of special tests such as X-rays, CAT scans and EKGs, and copies of pertinent surgical reports, hospital admitting history, physician discharge summaries, chart notes and narrative reports. The Standard states that it needs documentation of functional impairment, not only a diagnosis.
Part B states that the patient is responsible for the completion of the form without expense to The Standard. The Standard does not pay the physician for it, so any charge for completing the statement is handled between the practice and the patient.
It is a checklist in the Treatment section. You can mark malingering; a significant emotional or behavioral disorder such as depression or anxiety; exaggeration, inconsistent findings or complaints out of proportion to objective findings; dependence on drugs or medication, with details; or other factors, with a description. Leave items unchecked when they do not apply.