ATTENDING 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]