Short Term Disability Claim Statement Template (Page 2 of 2) in pdf

THE PATIENT MUST PAY ANY COSTS FOR COMPLETION OF THIS FORM

PART 3 - To be completed by Attending Physician (Please print or type. If necessary, attach separate sheet).

Patients Name

Patients DOB

Patient's symptoms result from (Check all that apply):

 Illness  Auto Accident  Other Accident  Pregnancy ____/____/____ Type of delivery ______________

Expected/Actual delivery date

Date symptoms first appeared ____/____/____

Please fully describe the patients limitations.

When did these limitations apply (Date of Disability)?

Began ____/____/____

Anticipated reduction ____/____/____

Anticipated Return to work date ____/____/____

Hospital Name

Confinement dates

____/____/____ thru ____/____/____

Dianoses with ICD9-CM Codes: List in descending order (including any complications). Please go to the appropriate assessment section and elaborate

Subjective symptoms

Objective Findings

Attach medical records which document the above diagnosis (Include results/copies of x-rays, lab tests, EKGs, MRIs, and Scans). Do you believe a legal

 Yes

 No

guardian or conservator should be appointed for this patient?

First visit for this condition ____/____/____ Most recent visits ____/____/____ Most recent comprehensive exam ____/____/____

Describe the treatment program and give dates of any surgery, medications (dosage/administrations routine), physical therapy, or psychotherapy.

Frequency of Treatment:  Weekly  Monthly  Other (Specify) ______________

 Class 1 - No limitation; capable of heavy work* - exert 50-100# occasionally and/or 25-50# force frequently.

 Class 2 - Medium activity* - exert occasionally 20-50# force and/or 10-25# force frequently.

 Class 3 - Slight limitation; capable of light work* - exert occasional 20# force and/or up to 10# force frequently.

 Class 4 - Moderate limitation; capable of sedentary* - clerical or administrative work - occasional 10# force, mostly sitting.

 Class 5 - Severe limitation; incapable of minimal activity or sedentary work*  Bed confined  House confined

 Remarks

*As defined by the U.S. Department of Labor's Federal Dictionary of Occupational Titles

List the patient's DSM-IV Axes:

III

V _____________Date___/___/___

Highest GAF in past year_____________Date___/___/___

Please define stress as it applies to this patient.

What stress and problems in interpersonal relations has patient had on the job?

Please fully describe the patient's limitations.

 Yes (Describe)  No (Explain)

Is patient a candidate for vocational rehabilitation services?

Describe any job modifications that would aid your patient in performing his/her work tasks.

Has patient reached maximum medical improvement?  Yes  No (Explain)

If "No", when? ____/____/____  Unknown

Physician's name

Degree

Specialty/Board Certification

Address

Telephone Number

Fax Number

Signature

Date

Physicians EIN or SSN

Return Form To: 5800 Foremost Drive • Suite 207 • Grand Rapids, Michigan 49546 • Fax (616) 808-2899

FORM-AMSTDC0907a

Short Term Disability Claim Statement

Short Term Disability Claim Statement Template Page 2

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