SHORT TERM DISABILITY CLAIM FORM PART C: ATTENDING PHYSICIAN’S STATEMENT:(To be completed by physician certifying disability on or after disability date to avoid processing delays) PATIENT’S NAME: DATE OF BIRTH: DATE PATIENT BECAME DISABLED DUE TO PRESENT DIAGNOSIS: WHEN DID SYMPTOMS FIRST APPEAR OR ACCIDENT OCCUR? HAS THE PATIENT EVER HAD SAME OR SIMILAR CONDITION/ DIAGNOSIS? YES/ NO DATE: _______________ IS THIS A WORKER’S COMPENSATION INJURY? NO/ YES IF “YES,” DATE ACCIDENT OCCURRED: NAMES/ADDRESSES ANY ADDITIONAL PHYSICIANS TREATING PATIENT FOR CURRENT DIAGNOSIS: DIAGNOSIS DIAGNOSIS: (INCLUDING COMPLICATIONS) ICD CODE (S): SUBJECTIVE SYMPTOMS: OBJECTIVE FINDINGS (INCLUDING CURRENT X-RAYS, EKG’S, LA BORATORY DATA AND ANY CLINICAL FINDINGS.) PREGNANCY: EDC: ___________ LMP: ____________ DATE OF DELIVERY: __________________ METHOD OF DELIVERY: � VAGINAL � CESAREAN SECTION PLEASE LIST ANY PREGNANCY COMPLICATIONS: TREATMENT DATE FIRST TREATED FOR THIS CONDITION LAST DATE TREATED FOR THIS CONDITION NATURE OF TREATMENT (SURGERY AND MEDICATIONS PRESCRIBED, IF ANY.) FREQUENCY OF TREATMENT: DID PATIENT HAVE SURGERY? IF YES: DATE OF SURGERY: TYPE OF SURGERY: PROGNOSIS HAS THE PATIENT: R IM E P T R R O OG VE R D E ? IS THE PATIENT: CONFINED FROM: TO: NAME AND ADDRESS OF HOSPITAL: (IF CONFINED) WHEN DO YOU EXPECT A FUNDAMENTAL CHANGE IN THE PATIENT’S CONDITION? (Please circle selection) 1 MO. 1-3 MO. 3-6 MO. 6-9 MO. 9-12MO. NEVER WHEN DO YOU ANTICIPATE A RETURN TO WORK FULL DUTY- WITHOUT RESTRICTIONS? IMPAIRMENTS WHEN COULD A TRIAL EMPLOYMENT COMMENCE? (IF PATIENT RELEASED TO RETURN TO WORK WITH RESTRICTIONS) DATE (PATIENT’S JOB): CAPACITY: FULL-TIME PART-TIME LIGHT DUTY PHYSICAL IMPAIRMENTS (AS DEFINED IN THE FEDERAL DICTIONARY OF OCCUPATIONAL TITLES) � CLASS 1 – NO LIMITATION OF FUNCTIONAL CAPACITY; CAPABLE OF HEAVY WORK. NO RESTRICTIONS (0-10%) � CLASS 2 – MEDIUM MANUAL ACTIVITY. (15-30%) � CLASS 3 – SLIGHT LIMITATION OF FUNCTIONAL CAPACITY; CAPABLE OF LIGHT WORK. (35-55%) � CLASS 4 – MODERATE LIMITATION OF FUNCTIONAL CAPACITY; CAPABLE OF CLERICAL/ADMINISTRATIVE (SEDENTARY) ACTIVITY. (60-70% (75-100%) � CLASS 5 – SEVERE LIMITATION OF FUNCTIONAL CAPACITY; INCAPABLE OF MINIMUM (SEDENTARY) ACTIVITY RESTRICTIONS AND LIMITATIONS: (What specific activities/ work duties is the patient incapable of performing) REMARKS: (Additional comments regarding the patient’s condition) NAME: (ATTENDING PHYSICIAN) FAX NUMBER: TELEPHONE NUMBER: MEDICAL ID NUMBER: ADDRESS: CITY: STATE: ZIP CODE: AUTHORIZED SIGNATURE OF PHYSICIAN “I hereby certify that the above described information is based upon reasonable medical probability, and is true and correct to the best of my knowledge and belief.” SIGNATURE: DATE: RECOVERED? IMPROVED? UNCHANGED? RETROGRESSED? AMBULATORY? HOUSE CONFINED? BED CONFINED? HOSPITAL CONFINED? IF CONFINED TO HOSPITAL, PLEASE PROVIDE DATES: CONTINENTAL AMERICAN INSURANCE COMPANY Post Office Box 84075 * Columbus, GA. 31993 Phone (800) 433-3036 * Fax (866) 849-2970