Trustmark Voluntary Benefits uses this 1-page statement for pregnancy claims under worksite disability coverage. The obstetric provider records the last menstrual period, first treatment date, complications, the date the patient was advised to stop working, delivery date and type, and any period of reduced capacity. Trustmark pairs it with the claimant's own pregnancy claim form.
The physician completes and signs the whole Attending Physician Statement, including specialty and contact details. The patient completes the separate pregnancy claim form, A112-2505, posted on the same Trustmark page.
Download the current version from the source each time; forms change without notice.
Pregnancy Disability Claim – Attending Physician Statement
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It asks for the last menstrual period, the date of first treatment for this pregnancy, the date you advised the patient to stop working, the estimated date of confinement or the actual delivery and discharge dates, and the from and to dates of any work restrictions.
Yes. The form asks the physician to attach copies of all medical records relating to the claim condition, including treatment notes and test results. It also asks you to list any complications of pregnancy on the form itself.