Guides · Disability claims
Attending physician statement: how to fill one out
- An attending physician statement is the disability insurer's form for the treating clinician. It supports the patient's claim for short-term or long-term disability pay.
- Every one I have read asks the same core things. The diagnosis, the symptoms, when you first and last saw the patient, when they stopped work, the treatment, what they cannot do, and for how long.
- The answers that bring a follow-up call are the vague ones. “No work”, “totally disabled” or a blank restrictions section tells the insurer very little.
- Each insurer has its own form. The sections below give each one's name and number and where to find the official blank.
What it is, and who sends it
When a patient can't work because of an illness, an injury or a pregnancy, and their employer offers short-term or long-term disability insurance, the insurer needs to hear from the clinician treating them. The attending physician statement (often shortened to APS) is the form for that. It is different from an FMLA certification. The FMLA form protects the patient's job while they are away, and the attending physician statement supports their claim to be paid while they are away, so a patient on leave often brings you both.
The form usually reaches you through the patient. The Standard's form, for example, says the patient is responsible for getting a completed form to them, and Prudential's claim packet tells the employee to ask their doctor to complete the statement and submit it to Prudential. MetLife's forms page says the physician completes it when the case manager asks for new or updated medical information, so you may see more than one over the course of a claim. Most forms print where to send it, usually a fax number and a post office box.
The questions every insurer asks
I compared the MetLife, Lincoln Financial and Standard forms side by side. The wording is different on each, but they all ask for these things.
| What they ask | What I would have ready |
|---|---|
| Diagnosis | The diagnosis and its ICD code, and any complications. |
| Symptoms | What the patient reports, in a sentence or two. |
| Dates | The first visit for this condition, the most recent visit, and the date the patient stopped work, or the date you advised them to. |
| Work related? | Whether the condition came from their job. If it did, it may be a workers' compensation claim instead. |
| Pregnancy | The expected or actual delivery date, if that is the reason. |
| Hospital and treatment | Any hospital stay, the treatment plan, and any surgery done or planned. |
| Restrictions and limitations | What the patient cannot do, specifically. This is the part the insurer reads most closely. |
| How long | When you expect them back at work, or how long the restrictions should last. |
Two of the three also ask for your objective findings, such as the exam, labs and imaging, and two ask whether the patient can do their own job or any job. Those are different questions, and it is worth reading each one carefully. Lincoln's form, for example, defines total disability as being unable to do the material duties of the patient's regular occupation.
The answers that bring a follow-up call
None of the forms ranks which answers cause problems, but several of them say plainly what they need, and that tells you what not to do.
- “No work” or “totally disabled” on its own. Unum's form says a reply like that
will not enable us to evaluate your patient’s claim for benefits
and may mean they have to contact you. It also asks you to put a number on words such as “prolonged”, “repetitive” or “heavy lifting”. What I do instead is name the activities, such as no lifting over 10 pounds, no standing longer than 20 minutes at a time, and a date or a time frame. - Leaving the restrictions blank. The Hartford's form says that if you don't list a restriction, they will conclude there is none. A blank there doesn't mean “not sure”, it means “no limits”.
- An incomplete form. MetLife's form says an incomplete form may delay the claim, and asks for your office notes and test results with it. New York Life's says the same about incomplete information.
- A missing time frame. Every form asks how long. If you honestly can't say yet, some forms give you a way to say that. The Standard's form, for example, has a choice for “Unable to determine, follow up in weeks”. That is better than leaving it blank, because a blank gets you a phone call.
Insurer by insurer
These are the insurers whose forms I see most often. Where an insurer posts its blank publicly, I link it. Group plans are sometimes printed for one employer, so if the patient brings you a different version, that is the one to complete.
MetLife
MetLife's form is the Disability Claims Attending Physician Statement, form APS-STD-LTD-5320, the 12/24 edition. It is six pages, covers both short-term and long-term disability, and has a grid for how many hours a day the patient can sit, stand, walk, reach and so on, plus strength levels for lifting and carrying. It is listed on MetLife's forms library. MetLife's FMLA certifications are separate forms. PatientPapers completes this one.
Lincoln Financial
Lincoln's form is the Attending Physician’s Statement, Short-Term Disability, form GLC-01817. It asks the usual questions and then a set about prognosis, including whether the patient is totally disabled from their present occupation and from all other occupations, and when trial employment could start. The official blank is on Lincoln's site (PDF). PatientPapers completes this one.
The Standard
The Standard's form is the Employee/Attending Physician’s Statement, SI 2047 APS, for short-term disability. The top of page 1 is the employee's to complete and sign, and the physician's part asks for the diagnosis, history and treatment, and the patient's functional limitations, and it asks you to attach recent chart notes. The official blank is on The Standard's site (PDF). PatientPapers completes the physician's part and leaves the employee's part blank for them.
Unum
Unum's short-term disability form is the Attending Physician Statement, form CL-1104, part of their short-term disability claim form. It is the one that warns about “no work” answers, so the restrictions section deserves the most care. Unum posts a copy of the CL-1104 (PDF), and Unum revises it from time to time, so if the patient brings you a newer edition, complete that one. This form isn't available in PatientPapers today.
The Hartford
The Hartford's form is the Attending Physician’s Statement – Initial, form LC-7135. It has a functionality grid, and it says that any function you don't restrict is taken as unrestricted. I could not find a public copy on The Hartford's own website, and it appears they send it for the specific claim or employer, so the copy the patient brings you is the one to use. This form isn't available in PatientPapers today.
Prudential
Prudential's form is the Group Disability Insurance Attending Physician Statement, form GL.2003.251. It is part of Prudential's initial claim packet (PDF), on pages 12 and 13. Some employers have their own printing of it with the employer's name at the top. This form isn't available in PatientPapers today.
Aflac
Aflac's group short-term disability claim form is issued by Continental American Insurance Company, and the physician's part is Part C, Attending Physician’s Statement. Parts A and B are the employee's and the employer's. It asks which specific activities or work duties the patient cannot do. I could not reach Aflac's posted copy when I wrote this, so I would use the packet the patient brings. This form isn't available in PatientPapers today.
Mutual of Omaha
Mutual of Omaha's attending physician statement is one section of its group disability claim form. In the current posted claim form (PDF) it is Section 5, Attending Physician’s Statement, near the end. Older short-term disability packets number it Section 3, so look for the heading rather than the number. This form isn't available in PatientPapers today.
New York Life
New York Life Group Benefit Solutions uses the Physician’s Statement of Disability, form GB-608066. It asks for the diagnosis, treatment, medications and physical limitations, and asks for medical documentation with it. The official blank is on New York Life's site (PDF). It does not print a fax number or address, so ask the patient where it goes. This form isn't available in PatientPapers today.
FAQ
What is an attending physician statement?
It is the disability insurer's form for the treating clinician. It asks for the diagnosis, the dates, the treatment, what the patient can and cannot do, and when they may return to work, so the insurer can decide a short-term or long-term disability claim.
Is an attending physician statement the same as an FMLA form?
No. The FMLA certification protects the patient's job while they are away, and the attending physician statement supports a claim for disability pay. A patient on leave often needs both, and the same insurer may send both, as MetLife does.
Can I just write that the patient cannot work?
I would not. Unum's form says a reply of no work or totally disabled will not enable them to evaluate the claim, and may mean they have to contact you. Name the specific activities the patient cannot do, and for how long.
Disclaimer: This article is general information for medical practices, not legal or insurance advice. Insurers revise their forms, and a group plan may use its own version, so the form the patient brings you is the one that counts. Form names, numbers and wording are from each insurer's form as posted or as the patient would bring it, read on October 1, 2026: MetLife APS-STD-LTD-5320 (12/24); Lincoln GLC-01817; The Standard SI 2047 APS (1/25); Unum CL-1104; The Hartford LC-7135; Prudential GL.2003.251; Aflac (Continental American Insurance Company) group short-term disability claim form, Part C; Mutual of Omaha group disability claim form; New York Life GB-608066. Insurer names are used only to identify their forms. PatientPapers is not affiliated with any of them.
Finish the statement faster.
I built PatientPapers to make this paperwork faster and easier. It is my own product, so weigh this accordingly. Today it completes the MetLife, Lincoln Financial and Standard attending physician statements above. It keeps your details on file, asks the questions in plain English, and fills in the insurer's own form for you to review and sign. Nothing you enter is sent anywhere. $250 per year or $25 per month, per certifying provider.