Trustmark Voluntary Benefits needs this 2-page statement to pay a disability income claim under coverage bought at the patient's workplace. The physician documents onset and treatment dates, primary and contributing diagnoses with ICD-10 codes, objective impairment, and restrictions and limitations. Page 2 is where the physician certifies total or partial inability to work, with dates and a return to work prognosis.
The attending physician completes both pages and signs page 2. The claimant and employer complete the separate initial claim form, A112-2504, which Trustmark posts alongside this statement.
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Disability Benefits Claim – Attending Physician Statement
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Yes. Section III offers a third option: 'I refrain from making a certification regarding work capacity at this time.' The other two options certify total or partial inability to work, each with from and to dates and a prognosis for return to work.
Section I asks you to describe objective evidence for loss of physiologic, mental or anatomic function, including pertinent physical exam and diagnostic results. Section II then asks for the restrictions and limitations based on that documented impairment.
The claimant and employer use the initial claim form A112-2504, posted on Trustmark's Voluntary Benefits forms page next to this separate physician statement. The statement itself also asks whether another physician referred the patient and whether the condition relates to the patient's employment.