18664248482 2025

1. Click ‘Get Form’ to open the Attending Physician’s Statement for Disability Claim in the editor.
2. Begin by entering the Claimant's Name and Date of Birth at the top of the form. Ensure accuracy as this information is crucial for identification.
3. In Section #1, describe the condition by filling in the ICD codes and primary diagnosis. Include any secondary diagnoses and specify when symptoms first appeared.
4. Indicate if there was an accident date and whether the condition is work-related. If applicable, provide details regarding pregnancy complications.
5. Move to Section #2 to document treatment required. Fill in consultation dates and indicate if hospitalization or surgical procedures were necessary.
6. In Section #3, outline any restrictions or limitations on work capacity. Specify if the patient can perform their job duties and when they are expected to resume work.
7. Complete Sections #4, #5, and #6 by providing physician details, signing, and certifying that all information is accurate before submission.

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