Get Attending Physician's Statement Short-term Disability

Filling out the Attending Physician's Statement Short-Term Disability form is an essential step in supporting individuals seeking disability benefits. This guide will provide you with detailed, step-by-step instructions to help you complete the form with confidence.

Follow the steps to accurately complete the form.

1. Click the ‘Get Form’ button to access the Attending Physician's Statement Short-Term Disability form and open it in an online editor.
2. Enter the patient's name in the designated field. Ensure the name is spelled correctly to avoid any processing delays.
3. Input the date of birth for the patient. This information is crucial for identification purposes.
4. Specify when the patient's symptoms first appeared or the date of the accident. Accurate dates will aid in the review process.
5. Record the date the patient ceased work due to their disability. This information is vital in assessing the claim.
6. Indicate whether the patient has had a similar condition in the past by selecting 'Yes' or 'No' and provide details if necessary.
7. State if the condition is related to a work injury or sickness. If 'Yes', include details of the incident.
8. List the names and addresses of any other treating physicians to provide a comprehensive view of the patient's care.
9. Document the diagnosis, including any complications that may impact the patient's condition.
10. If applicable, fill in the estimated date of delivery for patients who are pregnant.
11. Detail the subjective symptoms reported by the patient. If symptoms are unknown, select the appropriate option.
12. Provide objective findings including any current x-rays, EKGs, laboratory data, and relevant clinical findings.
13. Enter the date of the patient's first visit related to the current health condition.
14. Record the date of the last visit to ensure a complete treatment timeline.
15. Indicate the frequency of visits (Weekly, Monthly, Other) and specify as needed.
16. Describe the nature of treatment, including any surgeries or prescribed medications.
17. Assess the patient's recovery status by selecting options like 'Recovered', 'Improved', 'Unchanged', or 'Regressed'.
18. State whether the patient has been hospital confined, and if so, provide the name and address of the hospital.
19. Classify the patient's confinement status as 'Ambulatory', 'House Confined', 'Bed Confined', or 'Hospital Confined' and specify dates.
20. Complete the prognosis by answering questions regarding total disablement from the present occupation and other occupations.
21. Include remarks about limitations or therapy to provide additional context for the patient's condition.
22. Print the name of the attending physician in the specified field.
23. Indicate the physician's degree to establish their qualifications.
24. Provide a contact telephone number for the attending physician.
25. Complete the physician's address to ensure correct correspondence.
26. Finally, the physician must sign the form by writing their signature and include the date to authenticate the information provided.
27. Once completed, users can save changes, download the document, print it, or share it as needed.

Complete your Attending Physician's Statement Short-Term Disability form online to ensure prompt processing of your disability claim.