Physician statement form 2026

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The document is a Physician's Statement of Disability form used by various life insurance companies, including CIGNA and Great-West Healthcare. It requires detailed medical information from both the patient and their physician to support disability claims. The form includes sections for diagnosis, treatment, physical and mental impairments, and return-to-work status. Additionally, it contains a fraud warning highlighting the legal consequences of providing false information in insurance claims.

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Click ‘Get Form’ to open the physician statement form in our editor.
Begin by filling out the patient/insured section. Enter the patient's name, employer name, address, social security number, and contact details. Ensure all information is accurate for smooth processing.
Proceed to the diagnosis section. The physician should provide a detailed diagnosis including any complications, subjective symptoms, and objective findings. Attach relevant medical documentation such as X-rays or lab results.
In the treatment section, document any treatments provided, including medications prescribed and dates of hospitalization or surgery if applicable.
Complete the physical limitations section by indicating the patient's ability to perform various tasks during an 8-hour workday. This includes lifting and carrying capabilities.
Finally, fill out the return to work status and remarks sections. The physician must sign and date the form before submission.

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Versions	Form popularity	Fillable & printable
2012	4.8 Satisfied (65 Votes)
2010	4.1 Satisfied (56 Votes)

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What is a physician statement?

An Attending Physician Statement (APS) is a detailed medical report prepared by a patients primary or attending physician, typically in the form of a questionnaire. It provides comprehensive information to insurance companies about a patients health condition, medical history, and ongoing treatment plan.

What is an example of a physician attestation statement?

I, (print full name of physician/practitioner), hereby attest that the medical record entry for [date(s) of service/visit/progress note] accurately reflects signature/ notations that I made in my capacity as a(n) (the authors

How to get a physicians statement?

How to get an Attending Physician Statement. Speaking with your doctors about the APS and reviewing the document before submitting it to your insurance provider can mitigate many issues. Doctors are busy people and because drafting an APS isnt a priority, its not uncommon to find errors in their statements.

What does statement mean in medical terms?

Medical statement means a written document, on appropriate letterhead, which reflects a full diagnosis of the illness or injury and a prognosis, including anticipated date of recovery executed by a licensed health care practitioner qualified to make such a diagnosis and prognosis.

What is the purpose of an attending physician statement?

It provides comprehensive information to insurance companies about a patients health condition, medical history, and ongoing treatment plan. Insurance companies often request an APS during the application process to better understand the patients medical condition and make informed decisions about a claim.

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What is included in an Attending Physician Statement?

This Attending Physicians Statement template is designed to document a patients critical illness diagnosis, treatment history, and prognosis for insurance claim evaluation. It includes sections on medical findings, test results, and details on the patients limitations due to illness.

What is the physician statement for life insurance?

This document, which life insurance carriers typically request during the underwriting process, provides detailed medical information from your attending physician and offers insights into your health history, current medical conditions, and past and current treatments.

Who fills out an Attending Physician Statement?

Your doctor should complete all questions on the form. Any missed questions may raise red flags with your insurance company.