Doctor Statement Form PDF Details

A Doctor Statement Form is a document used to provide information about a patient's medical condition. The form can be used by healthcare professionals to help treat the patient, or by insurance companies when reviewing a claim. The Doctor Statement Form typically includes the patient's name, date of birth, and other identifying information, as well as a description of the medical condition. The form may also include contact information for the doctor who provided the statement, as well as their signature certifying its accuracy. It is important to complete all sections of the form accurately and legibly so that it can be properly processed.

This article offers information regarding doctor statement form. You may want to read it just before typing in the gaps.

Form NameDoctor Statement Form
Form Length2 pages
Fillable fields23
Avg. time to fill out5 min 6 sec
Other namesstatement doctor from template, doctor statement, doctor form fill, doctor form

Form Preview Example

Doctor’s Statement Form

The Internal Revenue Service requires a doctor’s statement be provided for certain healthcare expenses in order to be reimbursed from your healthcare Flexible Spending Account (FSA) or Health Reimbursement Arrangement (HRA). The doctor’s statement must indicate the specific medical disorder, the specific treatment needed, and how this treatment will alleviate the medical condition.

This form will assist you and your healthcare provider in providing the information we need in order to process your reimbursement request. Your provider can also write a letter on his or her letterhead, as long as the letter includes all the information on this form.

In addition to the information from your provider, certain expenses require a “but for” statement from the employee noting that the expense would not have been purchased had it not been for the provider’s recommended treatment plan. A “but for” certification section is also included in the form, which should be completed by you to ensure all required information is on file.

For fast and accurate processing of your reimbursement request, please make sure to include this doctor’s statement form or your provider’s letter and the employee “but for” statement along with an itemized receipt or other documentation. The reimbursement request claim form can be found on the self- service employee web site provided by your employer. Please be sure to print the requested information clearly on all documentation submitted.

Please note: If your treatment extends beyond the time period listed by the provider, you will need to submit a new doctor’s statement form upon expiration of the initial treatment dates. The maximum time period provided on the form cannot exceed one year from the date of the doctor’s signature. If treatment extends beyond one year, a new form will be required at the end of each one-year period.

Send the completed form with the signature of the healthcare provider and participant to:


Spending Account Management

1-866-643-2219 Toll-free


ADP Spending Accounts

P.O. Box 34700

Louisville, KY 40232

Submission of this form is not a guarantee that the expense will be reimbursed.


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Doctor’s Statement Form

Please print clearly with blue of black ink or type. Signature sections must be signed.

Employee name

Alternate ID/SSN




Patient name

Diagnosis/Diagnosis code

CPT code

Recommended treatment (must be explained in detail)

How will the recommended treatment alleviate the diagnosis or symptoms?

Date treatment began

How long is the treatment required?

Additional comments

Provider name and title

Provider address

Provider phone

Provider license # and state

Provider signature


Employee certification

By signing below, I certify that this expense would not have been incurred “but for” the

recommendation of the healthcare provider.




Employee signature




Employee printed name








© 2012

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How to Edit Doctor Statement Form Online for Free

Our PDF editor was designed to be as clear as possible. Once you try out the following steps, the procedure for managing the doctor required letter document will be stress-free.

Step 1: In order to start, select the orange button "Get Form Now".

Step 2: At the time you get into the doctor required letter editing page, you'll see lots of the options you can take with regards to your document at the top menu.

It is important to provide the next data so that you prepare the document:

part 1 to completing doctor forms to fill out

Put down the data in the Datetreatmentbegan, Howlongisthetreatmentrequired, Additionalcomments, Providernameandtitle, Provideraddress, Providerphone, Providerlicenseandstate, Providersignature, and Date area.

Completing doctor forms to fill out step 2

You'll have to put down certain particulars within the area Employeecertification, Employeesignature, Employeeprintedname, Date, and Pageof.

stage 3 to completing doctor forms to fill out

Step 3: After you've hit the Done button, your file will be accessible for transfer to any electronic device or email you indicate.

Step 4: Produce duplicates of the template. This would save you from possible difficulties. We cannot see or distribute the information you have, thus be certain it will be safe.

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