Aetna Attending Physician Statement PDF Details

The Aetna attending physician statement is a document that provides information on the care and services that were rendered by the attending physician. The statement can be used to support claims for reimbursement or to provide information to patients. The statement should include the name of the patient, the date of service, and a description of the care and services provided.

You could find it useful to know how much time you'll need to prepare this aetna attending physician statement and exactly how lengthy this document is.

QuestionAnswer
Form NameAetna Attending Physician Statement
Form Length4 pages
Fillable?Yes
Fillable fields33
Avg. time to fill out7 min 36 sec
Other namesaetna short term disability, ups employee aetna short term disability forms, aetna short term disability claim forms, aetna short term disability form

Form Preview Example

Adult Medical Attending Physician Statement

Attending Physician Instructions:

Complete the entire form and return to the employee.

1. Patient Information

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Aetna ID Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birth Date (MM/DD/YYYY)

Gender

 

 

 

 

 

Height (ft., in.)

 

Weight (lbs.)

 

 

 

 

Blood Pressure

Date Measured

 

/

 

/

 

 

 

 

 

Female

Male

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Diagnostic Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Diagnosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ICD-9 Code(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

,

 

 

 

 

 

,

 

 

 

 

 

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complications

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Objective Findings

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Subjective Symptoms

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are there any secondary conditions contributing to this condition?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

If Yes, what are they?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has this patient ever had the same condition or a similar condition?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

If Yes, what year(s)/describe?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Treatment Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Diagnosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date symptoms first appeared (or date of accident)

Date first treated for this condition

 

 

Most recent date treated for this condition

 

/

 

/

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Frequency with which you see this patient:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weekly

 

 

Monthly

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has the patient undergone surgery?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

If Yes, provide date

 

 

Procedure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Result

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ICD-9 Code(s)

 

 

 

 

 

 

 

 

 

 

If No, do you expect surgery to be performed in the future?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If Yes, provide date

 

 

 

Procedure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please list current medications with dosage and frequency.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please list other types and frequency of treatment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has the patient been referred to a medical rehabilitation or therapy program?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

If Yes, please describe facility and provide facility name, address and telephone number.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the patient a suitable candidate for vocational rehabilitation?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Please explain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has the patient been hospitalized for this condition?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

If yes, include dates of confinement as indicated.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.

Hospital Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospital Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment Dates

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From:

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To:

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

Hospital Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospital Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment Dates

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From:

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To:

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GC-1596 (1-14) A-POD

Adult Medical Attending Physician Statement

Page 2

Name

 

 

 

 

 

 

 

 

 

 

 

Birth Date (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

4. Progress

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Recovered

 

Improved

Unchanged

 

Retrogressed

 

 

 

Ambulatory

 

Home Bound

Bed Confined

 

Hospitalized

 

 

 

What is the prognosis?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has the patient achieved Maximum Medical Improvement?

If No, how soon do you expect fundamental changes in the patient’s medical condition?

Yes

No

 

 

1-2 months

3-4 months

 

5-6 months

More than 6 months

Please note any restrictions (activities your patient should not do).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please note any limitations (activities your patient cannot do).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What is the patient’s current work status?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please describe any physical and/or mental impairments.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date patient released from your care (if applicable)

 

Date patient able to return to full duty

 

 

 

 

/

/

 

 

 

 

/

 

/

 

 

 

 

 

 

5. Level of Impairment

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical Impairment (if applicable):

 

Does this patient have a mental/nervous impairment

Class 1. No limitation of functional capacity/capable of

impacting his/her level of functioning?

 

 

heavy work.

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

Class 2. Slight limitation of functional capacity/capable of

If Yes, provide diagnosis

 

 

 

 

medium manual work

 

 

 

Mental/Nervous Impairment (if applicable):

 

 

Class 3. Moderate limitation of functional capacity/capable

No limitation: able to function under stress and engage in

of light work.

 

 

 

 

interpersonal relationships.

 

 

 

Class 4. Marked limitation of functional capacity/capable

Slight limitation: able to function in most stress situations

of sedentary work.

 

 

 

 

and engage in most interpersonal relationships.

Class 5. Severe limitation of functional capacity/incapable

Moderate limitation: able to engage in only limited stress

of sedentary work.

 

 

 

 

and limited interpersonal relationships.

 

 

 

 

 

 

 

 

Marked limitation: unable to engage in stress or

 

 

 

 

 

 

interpersonal relationships.

 

 

 

 

 

 

 

 

 

Severe limitation: has significant loss of psychological,

 

 

 

 

 

 

physiological, personal and social adjustment.

Cardiac Functional Capacity – NY Heart Association:

 

 

 

 

 

 

 

 

 

 

 

Class 1. No limitation

Class 2. Slight limitation

Class 3. Moderate limitation

 

Class 4. Complete limitation

Do you believe your patient is competent to endorse checks and direct the use of the proceeds thereof?

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Comments/Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Attending Physician Information

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

Degree/Specialty

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

Fax Number

 

 

 

 

 

 

Board Certified

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Physician’s Signature

 

 

 

 

 

 

 

 

 

 

Date (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

The Genetic Information Non-Discrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you 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’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

GC-1596 (1-14)

Adult Medical Attending Physician Statement

Page 3

Name

8. Misrepresentation

Birth Date (MM/DD/YYYY)

/ /

Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Attention Alabama Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.

Attention Arkansas, District of Columbia, Rhode Island and West Virginia Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Attention California Residents: For your protection California law requires notice of the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Attention Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

Attention Florida Residents: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Attention Kansas and Missouri Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto may have violated state law.

Attention Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Attention Louisiana Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application is guilty of a crime and may be subject to fines and confinement in prison. Attention Maine and Tennessee Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.

Attention Maryland Residents: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Attention New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance policy or knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

Attention New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation.

Attention North Carolina Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and subjects such person to criminal and civil penalties. Attention Ohio Residents: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Attention Oklahoma Residents: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Attention Oregon Residents: Any person who with intent to injure, defraud, or deceive any insurance company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto may have violated state law.

Attention Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Attention Puerto Rico Residents: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or file, assist or abet in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years.

Attention Texas Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any intentional misrepresentation of material fact or conceals, for the purpose of misleading, information concerning any fact material thereto may commit a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties.

Attention Vermont Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties.

Attention Virginia Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent act, which is a crime and subjects such person to criminal and civil penalties.

Attention Washington Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

GC-1596 (1-14)

Page 4

Capabilities and Limitations Worksheet

Complete and sign the form using BLUE or BLACK ink.

Employee Name (Last, First, Middle Initial)

Aetna ID Number

Birth Date (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

Gender

 

Job Title

 

 

 

 

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Diagnosis

 

 

 

Medications

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Indicate the percent of the day the following activities can be performed:

(Occasional 1-33% or .5-2.5 hrs. Frequent 34-66% or 2.6-5.0 hrs. Continuous 67-100% or 5.1-8 hrs. or Never)

O F C N

Climbing

Crawling

Kneeling

Lifting

Pulling

Pushing

Reaching above shoulder

Forward reaching

Carrying

Bending

Twisting

O F C N

Hand grasping

 

 

 

 

R

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Firm hand grasping

 

 

R

 

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fine manipulation

 

 

R

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R

 

 

L

Gross manipulation

 

 

 

 

Repetitive motion

 

 

R

 

 

L

 

Sitting

 

R

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Standing

 

 

R

 

 

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Stooping

 

 

R

 

 

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Walking

 

 

R

 

 

L

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maximum weight patient is capable of lifting:

 

 

 

Approved head and neck movements:

 

 

 

 

 

 

 

 

 

Yes

No

 

1 - 5 lbs.

O

F

C

N

 

Static position

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Frequent flexing

 

 

 

 

 

 

6 - 10 lbs.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Frequent rotation

 

 

 

 

11 - 20 lbs.

 

 

 

 

 

 

 

 

 

 

21 - 35 lbs.

 

 

 

 

 

Can the patient operate:

 

 

 

 

 

 

36 - 50 lbs.

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

51 - 75 lbs.

 

 

 

 

 

 

A motor vehicle?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

75 - 100 lbs.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hazardous machine?

 

 

 

 

100 lbs. +

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Power tools?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Limitations to:

 

 

 

 

 

Exposure limitations: Yes

No

Yes No

 

Speaking

 

 

hrs.

 

 

 

 

 

Heat

 

 

Dust

 

Vision (explain)

 

 

 

 

 

 

 

Cold

 

 

Fumes

 

Depth perception

 

 

 

 

 

 

 

Dampness

 

 

Chemicals

 

Hearing (explain)

 

 

 

 

 

 

 

Noise

 

 

Radiation

 

 

 

 

 

 

 

 

 

 

 

Total # of hours patient is capable of working per day:

12

8

6

4

 

2

 

 

 

Duration of restrictions

 

 

Care complete: Yes

No

Next appointment

 

 

 

 

Additional Comments:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician’s Signature

Date (MM/DD/YYYY)

GC-1596 (1-14)

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part 1 to filling out aetna short term disability claim forms

Put down the details in the Date symptoms first appeared (or, Date first treated for this, Frequency with which you see this, Weekly, Monthly, Other, Most recent date treated for this, Has the patient undergone surgery, Yes, No If Yes, Result If No, Procedure, Procedure, ICD, 9 Code, s Yes, and Please list current medications field.

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End by analyzing all of these sections and completing the proper data: What is the prognosis, Class 1, Does this patient have a, Yes, If Yes, No limitation: able to function, Cardiac Functional Capacity – NY, Class 1, Class 2, Class 3, Class 4, Do you believe your patient is, and Yes.

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