The disability packet: the Attending Physician Statement

Before you start: who is asking, and why this is not the FMLA form

An Attending Physician Statement comes from a disability insurer, or from the company that handles its claims. Your patient has a policy, often through their employer, that pays part of their wage while they cannot work, and the insurer will not pay until a clinician says what is wrong and for how long. That is the whole purpose of the form. Nobody is asking you to decide whether your patient deserves the money; you are asked to describe the condition, what it stops them doing, and when you expect that to change.

Two things follow from that, and both are the opposite of the FMLA form. First, your patient has signed a release. On MetLife’s form it is printed in Section 1, above your part: your patient authorises you to release to the insurer any information collected in examining or treating them. So the diagnosis is not something to leave out here; the form asks for it by name and by code, and a statement without it is incomplete. Second, the insurer wants your evidence, not only your conclusion. MetLife asks you to send office notes and test results with the form; The Standard asks you to attach recent chart notes. Send what supports the dates you certify, and nothing about conditions the claim is not for.

The carrier sets the deadline, usually 10 to 15 days from its request, and it is printed on the cover letter, not on the form. Carriers accept that you may charge for this: MetLife’s form tells the patient, in its first paragraph, that some physicians charge and the charge is the patient’s responsibility. If you do, see the charging page; the same rules apply.

The three forms read for this page are MetLife’s seven-page statement, Lincoln’s three pages and The Standard’s two. They ask the same questions in a different order, so the rest of this page walks the questions, not the pages, and names the box on each form where it helps.

The dates: when it started, and when they stopped work

Every form asks for the same four dates: when the symptoms first appeared or the injury happened, the first visit for this condition, the most recent visit, and the date your patient stopped work because of it. MetLife asks the last one as a question, “Did you advise your patient to stop working? Yes, on date”; The Standard asks for the date you recommended they stop; Lincoln asks for the date the patient ceased work.

Write the day they could no longer do the job, which is often not the day they saw you. If your patient stopped work on a Tuesday and came in on the Friday, the date disability began is the Tuesday. A visit date written here instead shortens the claim by the gap, and the carrier does not know to ask.

Two yes-or-no questions sit beside the dates and matter more than they look. “Is the condition work-related?” routes the claim to workers’ compensation if you tick yes, and the disability carrier may stop paying while that is sorted out; tick it only when you mean it. “Has the patient ever had the same or similar condition?” (Lincoln item 6, The Standard item 3C) is about a pre-existing condition clause in the policy. Answer it honestly and briefly; the carrier will read the notes anyway, and a “no” the notes contradict is worse than a “yes” with a date.

Diagnosis, symptoms and what you found

Each form asks for the primary diagnosis and its ICD code, any secondary diagnosis, the symptoms your patient reported, and your findings: what you saw on examination, and what imaging and laboratory results showed. Lincoln puts symptoms in item 11 and findings in item 12; MetLife asks for the symptoms “your patient reported to you” and then your “clinical findings and reports”; The Standard asks for the diagnosis, the symptoms, and height, weight and blood pressure on the same line.

Write the diagnosis the claim is for, with the code the form asks for, and keep the findings box specific: the examination finding, the imaging result, the laboratory value, with dates. “Chronic back pain” with nothing under it is the first thing an examiner queries. A diagnosis is a name; the findings are the evidence for the dates you are about to certify, and a claim with the name but not the evidence is the one that draws a request for more.

The symptoms box is your patient’s account and is read as such. It does not substitute for findings, and findings do not substitute for it; fill in both. Limit everything to the condition the claim is for. The release your patient signed covers what the insurer needs to decide this claim, not their whole chart.

Treatment, surgery, hospital stays and referrals

Describe the treatment plan and how long it will run: the medication, the therapy, the surgery, the follow-up. If surgery has happened or is planned, MetLife wants the CPT code, description and date; The Standard wants the date and the reason and whether there were complications. A hospital stay wants the facility, the admission date and the discharge date. Referrals want the specialist’s name and specialty.

The frequency-of-visits box (Lincoln item 15, The Standard item 3G: weekly, monthly, other) is read against the duration you certify. Three months of disability with “no follow-up planned” is a contradiction; write the review visit you actually intend.

Unlike the FMLA form, naming the medication here is expected and does no harm the release does not already allow. What the carrier is reading for is whether the treatment matches the diagnosis and the dates.

The status boxes

Lincoln asks two questions with tick boxes: has the patient recovered, improved, stayed unchanged or regressed (item 17), and is the patient ambulatory, house confined, bed confined or hospital confined (item 18). MetLife asks instead whether your patient is at maximum medical improvement, which is a different question: not “are they better” but “are they as good as they are going to get”.

These boxes take two seconds and they are read. A patient marked “recovered” with six more weeks of disability certified below is a contradiction the examiner will ask about, and so is “bed confined” for someone you have written a physical therapy plan for. Tick the box that matches the rest of the form, and if none does, leave a note in the remarks box saying why.

The definition printed on the form

Most statements print the policy’s definition of disability, and you are certifying against that definition, not against your own sense of the word. Lincoln prints two. Total disability means your patient cannot perform the material duties of their regular occupation, and the form adds that a person working for wage or profit is not totally disabled. Partial disability means they cannot perform one or more of those duties, or cannot perform them full time.

So the question is about the job your patient actually has. A warehouse picker with a lifting limit of ten pounds is totally disabled from that job; an accountant with the same limit is not. Some long-term policies switch, after a period, to an any occupation standard, which asks whether your patient could do any job their education and experience fit. The form tells you which standard applies. Read it before you answer the prognosis questions, because they are asked in its terms.

Restrictions and limitations: what your patient cannot do, in numbers

This is the box that decides whether the claim is paid, and the one clinicians most often fill in with a conclusion instead of the facts. A restriction is what your patient should not do; a limitation is what they cannot do. The carrier needs both as functions with numbers, because it is comparing them to a job description you have not seen.

MetLife makes the numbers unavoidable: a grid of how many hours in a workday your patient can sit, stand, walk, climb, bend, reach and use their hands, then how many hours they can lift, carry, push or pull in weight bands from ten pounds to over a hundred, then whether they can drive. Lincoln and The Standard give you a blank box instead (Lincoln item 21, The Standard item 4A: “physical and/or mental limitations and restrictions”), and the right answer for the blank box is the same as the grid. “No lifting over 10 pounds. Sitting limited to 30 minutes at a time, up to 4 hours a day. No driving while on this medication. Unable to sustain concentration for a full shift.”

“Unable to work” is not a restriction. It is the conclusion the examiner is paid to reach, and a form that gives them the conclusion without the functions is the one that draws a call to your office. Mental limitations count and are asked for by name on The Standard’s form: concentration, memory, tolerance of a normal workplace, stated the same way, as what your patient cannot sustain and for how long.

Prognosis and return to work

MetLife asks whether you have advised your patient when they can return to work: to their regular occupation, on what date, full time, part time or on modified duty; or to any other occupation; or no, with an explanation. Lincoln item 20 asks five questions in the definition’s terms: totally disabled from the present occupation, totally disabled from all other occupations, can the present job be modified, do you expect a fundamental change, and when could trial employment begin, full or part time.

Answer each one with the printed definition in mind. “Totally disabled from all other occupations” is a much larger claim than the first question, and for a short-term claim the honest answer is usually no; the policy is not asking it yet. “Can the job be modified” is the question that gets your patient back to work sooner with a lighter role, so if the restrictions above allow it, say so. Give a date where a date is asked, and if you cannot, a review date; a prognosis with no date at all is read as “unknown”.

How long: the window you certify

The carrier pays through the period you certify and asks again at its end. Lincoln asks for it as dates of total disability, from and to. The Standard’s item 4C asks how long you expect the limitations to last and gives you three ways to answer: a date, “unable to determine, follow up in __ weeks”, or permanently. MetLife asks it through the return-to-work date.

Write a window that matches the expected recovery for this condition and this patient, with a review date. Six weeks for the fracture, twelve for the surgery, with the follow-up visit at the end of it. Where the form gives you a “follow up in N weeks” option, use it; it is the carrier telling you that a review date is an acceptable answer. Two answers stall the claim: a blank or “unknown” end date, which leaves the examiner with nothing to pay against, and a date so short that a second packet lands on your desk before your patient is back. Some carriers set a minimum period for a first statement; when the form says so, meet it.

“Permanently” is a real answer and a heavy one. It starts the any-occupation questions and the long-term review, so use it when it is true, not as a way to avoid choosing a date.

Signature, degree, and who may sign

Printed name, degree or specialty, address, telephone and fax, and on MetLife’s form your tax identification number. Lincoln’s signature line says “No stamps please”, and every carrier means it: a stamped signature is not accepted. Some carriers accept a nurse practitioner or physician assistant; some require a physician’s co-signature, and the form or the cover letter says which. MetLife also asks for the best person at your office to contact if they need more; give a name and extension, because the alternative is the examiner calling you between patients.

Sign the acknowledgement knowing what it says. The Standard’s reads that your answers are complete and true to the best of your knowledge, and every form carries the state fraud notices behind it. A best estimate, honestly made, is what is asked; a date you do not believe is not.