Attending Provider Statement: Universal

Medical
NOTE TO HEALTH CARE PROVIDER: Your patient has applied for disability benefits. Completion of this form is
necessary to review and process the request. PLEASE ANSWER ALL QUESTIONS.

Patient First Name: Last Name: Date of Birth: Gender:

Information
Statement of Do you consider your patient’s absence from work medically necessary? ☐ No
Work
Incapacity
☐ Yes, from: _____/_____/_____ Through: _____/_____/_____

If yes, explain how the patient’s severity of illness, relevant symptoms, exam finding(s) per
physical/mental status exam, and relevant diagnostic tests or treatment protocols preclude work:

Has patient been given any driving/operating machinery restrictions for this disability period?
☐ No
☐ Yes, please describe:

Disabling Primary Disabling Diagnosis: Date Diagnosed: _____/_____/_____ ICD code:

Diagnoses
Secondary/Co-Morbid condition impacting work: ICD code:

Tertiary/Co-Morbid condition impacting work: ICD code:

Please confirm whether the patient’s primary disabling condition is related to any of the following:
● Work related injury or illness: ☐ No ☐ Yes ☐ Unknown
● Any type of military service: ☐ No ☐ Yes ☐ Unknown
● Pregnancy: ☐ No ☐ Yes, expected/actual date of delivery: _____/_____/_____ C-section: ☐ No ☐
Yes

First Office Visit: Last Office Visit: Next Office Visit: Date Referred to Specialist:
Course of Care
_____/_____/_____ _____/_____/_____ _____/_____/_____ _____/_____/_____

Additional Name: Specialty: Phone Number:

Treating
Provider ☐ Not Applicable

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Medical ☐ Not Applicable ☐ Scheduled/Performed on the following date: _____/_____/_____
Procedures
& Hospitalization Description: ______________________ Surgical Approach: ______________ CPT Code(s): ___________
☐ Inpatient ☐ Outpatient

Postoperative Complications: ☐ N/A ☐ Present, describe:

Hospitalization: Admission Date: _____/_____/_____ Discharge Date: _____/_____/_____

Prescribed List all applicable prescribed medications including name, dose, frequency, start date, and date last titrated:
Medications

Medication side effects impacting work capacity: ☐ None ☐ Present; describe:

Medical Signs Date Measured: _____/_____/_____ Height: ______ Weight: ______ Pulse: ______ Respiration rate: ______
and Symptoms
Blood Pressure: _____/_____ O2 Sat: ______ on ☐ Room Air ☐ Supplemental Oxygen; liters: ________

Patient-reported complaints/symptoms impacting Activities of Daily Living (ADL’s) and work:

Physical Examination findings:

Relevant Diagnostic Findings (imaging, lab values, functional testing, e.g., pulmonary function tests,
cardiac tests, etc.):

Psychological or Please provide your provocative Mental Status Exam findings and Behavioral Observations as applicable.
Neurocognitive
Impairment Affect/Emotional Appropriateness and Control:
☐ Within normal limits (WNL) ☐ Impaired as evidenced by:
Behavioral Appropriateness/Control, Pace & Stamina:
☐ WNL ☐ Impaired as evidenced by:
Cognitive Processing/functioning:
☐ WNL ☐ Impaired as evidenced by:

Do you believe the patient is competent to endorse checks and direct the use of proceeds thereof? ☐ Yes
☐ No, please explain:

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 Return to Work Patient has sufficiently recovered to Return-to-Work per the following:
Status & Plan
1.* ☐ Released to Full time, Full Duty (no restrictions or limitations) as of _____/_____/_____
2.* ☐ Released to Modified/Transitional Duty on _____/_____/____ and Full Duty as of
_____/_____/_____
3.* ☐ Released back to work on _____/_____/_____ with permanent restrictions and/or accommodations:

*Note: If restrictions/accommodations are prescribed please specify the parameters with supporting
clinical rationale: No lifting >___ lbs., No pushing >___lbs., No pulling >___ lbs.,
Work hours/per day & days/week__________________ Other: _________________________

Rationale:

If patient has not yet sufficiently recovered to perform work in any capacity, estimate the following:

1. ☐ Return work date as of: _____/_____/_____

2. ☐ Significant clinical improvement by: _____/_____/_____

3. ☐ The patient will reach maximum medical improvement by: _____/_____/_____

4. ☐ The patient will need permanent work restriction and/or accommodations as follows (include rationale):

Conference If my patient’s work capacity is unclear and requires clarification, I would be willing to participate in a brief
Availability (5 to 10 minute) teleconference with a clinician.

☐ Yes, on the following days and time slots: Day(s) of the week: _________ Hours of the Day: ___________

☐ No, However, I would be willing to respond in writing to specific questions via email or _________________
Credentials Provider’s full name (please print): Specialty: Degree:

Address (No., Street, City, State, Zip Code): Phone: Fax:

Signature: Date Completed: _____/_____/_____

Version: 4-8-2022

Please fax to Client Fax.

Please see ADDENDUM for Genetic Information Nondiscrimination Act. DO NOT PROVIDE GENETIC Information.

| PCA Absence Management Center | PO Box 1552 | Lincolnshire, IL 60069-1552 |

| Phone: 1-877-453-0945 | Fax - 1-847-554-1958 |

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Addendum to Attending Provider Statement

IMPORTANT NOTICE REGARDING GINA

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by
GINA Title II from requesting or requiring genetic information of employees or their family members. In order to
comply with this law, we are asking that you do not provide any genetic information when responding to this request
for medical information.

“Genetic information,” as defined by GINA, includes an individual’s family medical history, the results of an
individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or
received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member
or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

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