18664248482 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Claimant’s Name and Date of Birth at the top of the form. This information is essential for identifying the claim.
3. In Section #1, describe the condition by filling in the ICD codes and primary diagnosis. Be thorough in detailing any secondary diagnoses and other conditions.
4. Indicate when symptoms first appeared and whether there has been a similar condition previously. If applicable, provide accident details.
5. Move to Section #2 to document treatment required, including consultation dates and any surgical procedures that were necessary.
6. In Section #3, specify restrictions and limitations regarding work capacity. Clearly state if the patient can perform their job duties or not.
7. Complete Sections #4, #5, and #6 with physician details, verification signatures, and certification statements to finalize the form.

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