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Disabled Child Attending Physician s Stmt Behvl Hlth Attending Physician s Stmt Disabled Child Atten

Disabled Child Attending Physician s Stmt Behvl Hlth Attending Physician s Stmt Disabled Child Atten 2025

Disabled Child Attending Physician s Stmt Behvl Hlth Attending Physician s Stmt Disabled Child Atten Preview on Page 1

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4.2 out of 5

68 votes

The document is a form for obtaining a physician's statement regarding a disabled child, detailing the necessary information to be filled out by both the employee and attending physician. It includes sections for employer, employee, and dependent child information, as well as specific medical and behavioral health conditions that need to be documented. The form also emphasizes the importance of accurate information to avoid fraudulent claims and provides guidelines for using Social Security disability criteria.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out Section 1, which requires employer information. Enter the name as shown on the ID card and the policy/group number.
Proceed to Section 2 for employee information. Fill in your name, ID number, and birth date in MM/DD/YYYY format.
In Section 3, provide details about the dependent child, including their name and birth date.
For Section 4, the attending physician must complete parts A and B if applicable. This includes diagnosis(es), date of onset, objective findings, and any additional clinical information.
Section C requires referencing Social Security disability guidelines to quantify the individual’s disability. Ensure you document diagnosis(es) and listing numbers accurately.
Complete Section 5 with the attending physician's contact information and signature. Finally, list any other treating physicians in Section 6.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (104 Votes)
2015	4.2 Satisfied (68 Votes)

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What is the attending physician statement for disability?

An Attending Physician Statement (APS) is a form questionnaire from the insurance company that your treating doctor must complete. The purpose of the APS is for your doctor to docHub your inability to work.

What is an example of a disability statement?

The insurance provider requires detailed evidence of how the condition affects the patients ability to work, so the attending physician completes an APS template to document the patients diagnosis, progressive symptoms, treatment plan, and specific functional limitations.

Who completes an attending physicians statement (APS)?

3. In general, refer to the person first and the disability second. UseDont Use Person with a disability, people with disabilities Disabled person; the disabled Man with paraplegia Paraplegic; paraplegic man Person with a learning disability Slow learner Student receiving special education services Special education student1 more row