DISABILITY BENEFITS LETTER: MEDICAL OPINION ON FUNCTION

[Practice name]
[Address]
[Phone and fax]

Date: [Date you sign the letter]
To: [Disability program, insurer's claims department, or appeals office]
Claim or file number: [Number on the patient's claim, if any]

Re: [Patient's full name]
Date of birth: [Date]

PURPOSE
[Patient name] asked me for my opinion on their function, for [a new claim, an appeal, or a review] of long-term disability benefits. They agreed to what this letter shares.

MY TREATING RELATIONSHIP
Role: [Family physician, specialist, nurse practitioner, or psychologist]
Treating them since: [Month and year]
Visits in the past 12 months: [Number], most recently on [date]
Tests and referrals I ordered: [List, or none]

CONDITIONS
[Each condition that limits function: when symptoms began, when and how it was diagnosed, and by whom]

OBJECTIVE FINDINGS
[Examination findings, imaging, nerve studies, lab results, and standardized scores, each with its date]
What I observed in visits: [For example gait, posture changes, slowed speech, or how long they sat]

TREATMENT AND RESPONSE
[Each treatment tried, with dates and doses or number of sessions, what changed, and why any was stopped]
Side effects that affect function: [None, or each side effect and what it limits]
Treatment followed as prescribed: [Yes, or what got in the way]

FUNCTIONAL LIMITATIONS
What [patient name] can do on a sustained basis, in my opinion, over a working day:
Sitting: [Minutes at one time; hours in total]
Standing: [Minutes at one time; hours in total]
Walking: [Distance or minutes at one time; hours in total]
Lifting and carrying: [Weight occasionally; weight often]
Bending, reaching, and use of hands: [Limits, or none]
Concentration, memory, and pace: [What they can sustain, and for how long]
Dealing with people, pressure, and change: [Limits, or none]
Time off task: [Estimated percent of a working day, or none expected]
Days missed: [Estimated days a month, or none expected]
Need to lie down or rest: [How often and for how long, or not needed]
Other: [Vision, hearing, environment, or none]
Basis for these limits: [The findings and observations each limit rests on]

ONSET, DURATION, AND PROGNOSIS
These limits began on or about [date], based on [my notes, earlier records, or the patient's account].
Expected to last: [Number of months, or indefinitely]
Prognosis: [Expected course, treatment still planned, and what could change it]
Next review: [Date]

NOT ASSESSED
[What I did not test or can't comment on, such as a formal functional capacity evaluation or which jobs they could do, or nothing]

Supporting records: [Attached, with their dates, or available on request with the patient's consent]
Questions about this letter: [Practice phone]

[Your name, credentials, specialty]
[License or registration number]
[Signature]