An attending physician statement is the medical report you complete for a disability, life, or critical illness insurer, or a benefits program: what you found, the treatment, what the patient can and can’t do, and when that should change. Copy the blank report or download it, with a back injury and a depression example, and how to write restrictions an insurer can use.
Blank attending physician statement template
FreeATTENDING PHYSICIAN STATEMENT: MEDICAL REPORT TO AN INSURER [Practice name] [Address] [Phone and fax] Date completed: [Date] To: [Insurer or benefits program, claims department] Claim, policy, or certificate number: [Number] Type of claim: [Short-term disability, long-term disability, critical illness, life insurance, workplace injury, or benefits program] Report: [First report, or an update to my last report and its date] Patient's authorization: [Signed release and its date, received with the request] PATIENT Name: [Patient's full name] Date of birth: [Date] Occupation: [Job title and employer] Main job demands: [Physical and mental demands of the job, as the patient describes them or as the employer's job description lists them] Last day worked: [Date, or still working] ATTENDING CLINICIAN [Your name, credentials, specialty] Relationship: [Family physician, treating specialist, nurse practitioner, or psychologist] since [month and year] First visit for this condition: [Date] Visits for this condition: [Each date, most recent first] Other clinicians treating this condition: [Name, role, and when they last saw the patient, or none] DIAGNOSIS Main diagnosis: [Diagnosis, with a code if the form asks for one] Other conditions that affect function: [List, or none] Symptoms began: [Date] Diagnosed: [Date, and how it was confirmed: examination, imaging, pathology, lab tests, or rating scales] Related to work: [Yes, no, or unknown] Hospital stays and surgery: [Dates and procedures, or none] OBJECTIVE FINDINGS Examination: [What you found, with the date of each finding] Tests and scores: [Imaging, lab, nerve study, or rating scale results, with dates] Change since the last report: [Better, the same, or worse, and the finding that shows it, or first report] TREATMENT Current treatment: [Medications with doses, therapy and how often, home program] Response: [What has changed, and by when] Following the treatment plan: [Yes, or what has got in the way] Next steps: [Referrals, tests, or changes planned, with dates] RESTRICTIONS AND LIMITATIONS Restrictions, activities [patient name] should not do: [Each activity, and the medical reason] Limitations, activities [patient name] cannot do: [Each activity, and the finding behind it] Frequency terms: occasionally means up to a third of the workday, frequently a third to two thirds, constantly more than two thirds Sitting, standing, and walking: [Minutes at a time, and how often] Lifting and carrying: [Weight in lb or kg, from what height, and how often] Bending, twisting, reaching, and hand use: [What to avoid or limit] Concentration, memory, and pace: [What they can sustain, and for how long] Stamina: [Hours a day and days a week of activity they manage now] Driving and machinery: [Allowed, limited, or not allowed, and why] In place until: [Date, or the next review] RETURN TO WORK Modified duties now: [Yes, within the limits above, or not yet, and why] Expected return: [Date or date range] Return plan: [Hours and duties, and how they increase week by week] PROGNOSIS Expected course: [Full recovery, partial recovery, or lasting limits] Expected improvement by: [Date] What could change it: [Treatment still to come, or barriers to recovery] Next review: [Date] OTHER Able to manage their own benefit payments: [Yes, no, or not assessed] Records attached: [Each report and its date, or none] I examined the patient and completed this report from my records. [Signature] [License or registration number] [Date signed]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Family physician; first report for a 46-year-old warehouse supervisor’s short-term disability claim
Short-term disability claim with his employer’s group insurer; first report. The request came on Monday, October 5, 2026, with his signed authorization dated Thursday, October 1. The insurer’s claim form asked for restrictions and a return plan in narrative form, so this report goes with it.
46-year-old warehouse supervisor at a distribution center, on 10-hour shifts, 4 days a week. He describes walking the floor for most of a shift, lifting cartons of up to 50 lb or 23 kg to help his team, driving a forklift for 1 to 2 hours a shift, and about 2 hours of desk work. Last day worked: Friday, September 11, 2026.
His family physician since 2019. Visits for this condition, all in person: Monday, September 14; Monday, September 21; and Tuesday, October 6, 2026. He sees a physiotherapist twice a week, since September 21.
Right S1 radiculopathy, most likely from an L5–S1 disc herniation, diagnosed by examination on September 14. Low back pain, and burning pain down the back of the right leg to the heel, began on Saturday, September 12, 2026, as he lifted a kayak onto his car. Not related to work. No hospital stays or surgery. MRI not done: there are no red flags, and imaging wouldn’t change treatment in the first 6 weeks. I will order one if the weakness worsens or the leg pain isn’t better by 6 weeks.
September 14: straight leg raise positive on the right at 35°; right ankle reflex reduced; less feeling along the outer edge of the right foot; 4 single-leg heel raises on the right against 15 on the left. No saddle numbness; bladder and bowel normal. October 6: straight leg raise positive at 55°; 9 right heel raises against 15 on the left; ankle reflex still reduced. He stood up twice during the 20-minute visit to ease his leg.
Naproxen 500 mg twice a day with food since September 14. Physiotherapy twice a week since September 21: directional exercises, nerve gliding, and walking 10 minutes 3 times a day. He has attended all 5 sessions and reports doing the exercises daily. Leg pain is down from 8 to 5 out of 10 by his report, and the leg raise and heel raises above have improved. If he isn’t improving by 6 weeks, on October 24, I will refer him to a spine clinic to consider an epidural steroid injection.
Restrictions, to protect recovery: no lifting from the floor, no forklift driving, and no repeated bending or twisting. Limitations, from the leg pain and calf weakness: sitting 20 minutes at a time, then 5 minutes standing or walking; standing 30 minutes at a time; walking 15 minutes at a time on level ground; lifting up to 10 lb or 4.5 kg between waist and chest height, occasionally. Driving his own car: trips of up to 20 minutes. In place until the review on Tuesday, November 3, 2026.
Modified duties now: not yet. His employer has offered desk-based scheduling work, but a sitting limit of 20 minutes doesn’t yet support a shift of it. Expected return: Monday, November 9, 2026, 8 weeks after onset, if the November 3 review confirms progress. Plan: weeks 1 and 2, 5-hour shifts of desk and scheduling work, sitting and standing as he needs, no lifting over 10 lb or 4.5 kg; weeks 3 and 4, 8-hour shifts adding floor supervision, lifting up to 25 lb or 11 kg occasionally, still no forklift; full duties and 10-hour shifts from Monday, December 7, if right calf strength is normal. Prognosis: good. Leg pain from a disc herniation like this usually settles within 6 to 12 weeks with this care, and his findings are improving.
Family physician; report for a 38-year-old payroll manager’s long-term disability claim
Long-term disability claim with her group insurer, as her short-term disability benefits end this month. Her signed authorization, dated Monday, October 12, 2026, came with the request. The insurer’s form left 4 lines for functional abilities, so I wrote “see attached” there and attached this report.
38-year-old payroll manager for a manufacturer with about 400 staff. She describes running payroll every 2 weeks to fixed bank deadlines, checking figures line by line, supervising 2 staff, and answering pay questions from employees. Desk-based, with no physical demands of note. Last day worked: Friday, April 24, 2026.
Her family physician since 2015. 9 visits for this condition since Monday, April 27, 2026, every 2 to 4 weeks, most recently in person on Tuesday, October 20. She has seen a psychologist weekly for CBT since Tuesday, May 12, 22 sessions so far, and a psychiatrist once, on Tuesday, September 29.
Major depressive disorder, single episode, severe at onset, without psychotic features. Symptoms began in about February 2026, with no single trigger she can name. Diagnosed at interview on April 27, 2026. No hospital stays. Passive thoughts of death in May, managed with a safety plan; none since June.
PHQ-9 of 21 on April 27, 17 on July 14, and 13 on October 20. TSH, blood count, and B12 normal on April 28. On October 20 I found her on time and well groomed, with an affect brighter than in the summer but still restricted. Her answers were slow, and she lost her place once while describing her week. The psychiatrist’s report of September 29 is attached.
Escitalopram 10 mg from April 27, raised to 20 mg on May 25. Bupropion XL 150 mg added on August 18 for low energy and poor concentration, as the response was partial. Weekly CBT since May 12. The psychiatrist agreed with the plan and advised 8 more weeks on it before any change. She has kept every appointment and reports taking her medicines daily. Sleep and mood are better; energy and concentration lag behind.
Restrictions: none needed for safety, and she can drive. Limitations, from her account and what I see in visits. Concentration: about 30 minutes of focused reading or figures before she loses track; she reports taking 2 hours to reconcile her household accounts last week and finding 3 errors later. Memory: relies on phone reminders and missed 1 appointment in August. Stamina: about 4 hours a day of light structured activity, such as walking, chores, and one errand, then rests for 1 to 2 hours. Pace: can’t yet work to a fixed deadline; a short deadline raises her anxiety and slows her further. People: manages one-to-one conversation; groups of more than 3 tire her quickly. In place until the review on Tuesday, January 19, 2027.
Modified duties now: not yet. Payroll needs sustained accuracy to a deadline every 2 weeks, which she can’t manage at present. Expected return: a graded return in about February 2027, once her PHQ-9 is below 10 and she has managed 6 hours of structured activity a day for 2 weeks. Likely plan: 3 half-days a week with no payroll-run deadlines for the first 4 weeks, building to full hours over 8 to 10 weeks. Prognosis: good to fair; her scores are falling steadily on treatment she is following. Next review on January 19, 2027, 3 months from now, with an update to the insurer after it. Able to manage her own benefit payments: yes.
Which insurer, which claim, and the patient’s permission to release what you write.
Avoid: Answering without a signed release. Insurers send one with the request; check that it names you and covers the records asked for.
Who the patient is and what their job asks of them, so the insurer can set the limits against the work.
Avoid: Stating the job demands as fact. Say whether they come from the patient or from a job description the employer sent.
How well you know this condition: when care started, and how often you have seen the patient for it.
Avoid: Leaving out the visit dates. Most disability policies require regular care while benefits are paid, and insurers check for it.
The condition, when it started, and how it was confirmed. For a critical illness claim, the date and basis of the diagnosis often decide it.
Avoid: A diagnosis with no dates. The insurer needs to know when the condition began and when it stopped the patient working.
What you saw, measured, and tested. The restrictions and limitations rest on this evidence.
Avoid: Findings with no dates. Insurers compare one report with the next, so date each finding and say what changed.
What the patient is doing to get better, whether it’s working, and what comes next.
Avoid: “Ongoing treatment.” Name each treatment, when it started, and what it changed.
What the patient can and can’t do. Insurers decide claims on function, so this part matters more than the diagnosis.
Avoid: “Off work” or “light duty” and nothing else. Give the insurer abilities it can match against the job.
When you expect function to improve, what a return would look like, and when you will look again.
Avoid: “Unknown” as the return date. Give your best estimate and a review date; you can revise both in the next report.
Two people with the same diagnosis can have very different abilities. Insurers pay for lost function, so say what the patient can and can’t do, in minutes, weights, and hours.
A restriction is something the patient should avoid, such as lifting from the floor while a disc settles. A limitation is something they can’t do, such as sitting past 20 minutes. Label each, so the insurer can tell precautions from current abilities.
Insurers weigh what you observed and measured. Keep the patient’s account, but write “he reports” for what you were told and “I found” for what you saw, and pair the two where you can.
An open-ended absence brings more requests. Give an expected date or range, the plan to get there, and when you will review it.
When the insurer sends its own statement, complete it: its questions follow its policy. Use this report where the form asks for a narrative or its boxes run out, and write “see attached” there.
Send what the insurer asked for and the patient authorized. Leave out unrelated history, such as past counseling in a back injury claim.
Vero Scribe writes the statement in your template from the visit, with the patient’s consent, or from your dictation. You review and edit every section, then copy it into the insurer’s form or your record, or export it to Word or PDF. Vero works in 60+ languages.
The medical report an insurer asks the treating clinician to complete for a claim or an application: the diagnosis and its dates, findings, treatment, restrictions and limitations, return to work, and prognosis. Disability insurers ask for one when a claim starts and again at intervals while it continues. Many send their own form; this template covers the same ground when they ask for a narrative or have no form.
Start with the claim details and the patient’s authorization. Then give your visit dates, the diagnosis with when it began and how it was confirmed, what you found, and the treatment and response. Set out restrictions and limitations with minutes, weights, and how often. End with an expected return date, the prognosis, and when you will see the patient again.
Restrictions are what the patient should not do, even if they could, to protect recovery or safety: no lifting from the floor after a disc injury. Limitations are what they can’t do because of the condition: sitting more than 20 minutes. Insurers ask for both, and for how long each will last.
Most insurer forms use them as shares of the workday: occasionally is up to a third, frequently is a third to two thirds, and constantly is more than two thirds. Check the definitions on the form you’re completing, and use the same terms in your report.
The attending physician statement is the insurer’s routine medical report, filed when a claim starts and at each update. A disability benefits letter is your own opinion letter, usually for a long-term claim, an appeal, or a review, with more detail on lasting limits and the evidence for each.
Yes. The insurer should send a release signed by the patient. Check that it names you and covers what’s asked, send only that, and give the patient a copy of your report if they ask.
For an application, the insurer is weighing risk, not function: each diagnosis with its dates, treatment and medications, test results, and how well each condition is controlled. Complete the sections it asks about, and leave out the work and function sections.
Yes. Copy it, or download it as a Word or text file. No account needed.
For work or school: the visit, the dates off, the return, and any limits.
To an employer: full or modified duties, the restrictions, how long they last, and the review date.
To an employer or leave administrator: when the leave starts, how long it lasts, the review date, and what the return needs.
To an employer: what the condition limits, the change that would help, how long, and answers to the employer’s questions.
To an employer: the pregnancy-related limitation, the change needed at work, and how long it lasts.
Work-related visits, job demands, and work-status documents.
Visit notes and the forms that follow them, drafted for your review.
Fill an insurer’s PDF form from the visit and the chart.
Disability, leave, and benefits forms, with official links and how to file them.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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