Arizona State Retirement System members who claim benefits under the ASRS Long Term Disability Income Program need objective medical evidence from their attending physician, supplied on this statement. It belongs to the LTD claim packet, which is not posted online; the member gets it from their employer's human resources office. The completed packet goes to Broadspire Services, the third-party administrator that handles ASRS LTD claims.
The member's attending physician or other licensed medical provider completes the attending physician section. The member and the employer complete their own forms in the same packet.
Download the current version from the source each time; forms change without notice.
Attending Physician's Statement of Patient Disability
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From the patient. The Arizona State Retirement System does not post the LTD claim packet online; members get it from their employer's human resources office, and the packet includes employee, employer and attending physician forms. The ASRS LTD Employee Guide names the physician's form as the Attending Physician's Statement of Patient Disability.
ASRS routes long term disability claims to its third-party administrator, Broadspire Services, Inc., which receives the full packet from the employer. Broadspire reviews the attending physician's objective medical evidence and may order an independent medical examination at no cost to the member.