Physician’s Statement of Disability / Functional Limitations (ICD Diagnosis Codes, Treatment, ADLs, and Return-to-Work) Instructions

Check/enter this box when recording the day (DD) the patient was first unable to bathe independently.

Enter the year when the patient was first unable to perform bathing (the date they first required assistance).

Check/enter this box when recording the month (MM) the patient was first unable to bathe independently.

Enter the year (e.g., 2026) when the patient was first unable to perform continence.

Check this box when entering the day (middle) portion of the date when the patient was first unable to complete the Continence activity.

Enter the numeric month (M) when the patient was first unable to perform continence.

Enter the year (e.g., YYYY) when the patient was first unable to complete the dressing activity.

Check this box to indicate the day portion of the date when the patient was first unable to complete dressing.

Check this box to indicate the month portion of the date when the patient was first unable to complete dressing.

Enter the month when the patient was first unable to complete the Eating activity of daily living.

Check this box when filling in the first date part (month) of the date the patient was first unable to eat; used to indicate the month in the MM / DD / YYYY eating date field.

Enter the year when the patient was first unable to complete the Eating activity of daily living.

Check this box to indicate the first date field (the first of the three date parts) for when the patient was first unable to perform toileting.

Enter the month (numeric) when the patient was first unable to perform toileting.

Enter the year when the patient was first unable to perform toileting.

Check this box to indicate the month (MM) when the patient was first unable to perform transferring.

Enter the year when the patient was first unable to perform transferring (use four digits, e.g., 2024).

Enter the month when the patient was first unable to perform transferring (use two digits, e.g., 03 for March).

Enter the date the physician advised the patient to stop working.

Check this box when you are indicating the day portion (day of month) of the date you advised the patient to stop work.

Check this box when you are indicating the year portion of the date you advised the patient to stop work.

Enter the year when the patient was first unable to perform cognitive functioning (the year they first experienced loss of cognitive functioning).

Check this box to indicate/record the month portion of the date when the patient first experienced loss of cognitive functioning.

Check this box to indicate/record the day portion of the date when the patient first experienced loss of cognitive functioning.

Enter the date when the hospital confinement began.

Check this box when you are indicating the month portion of the hospital confinement start date (the 'From' date).

Check this box when you are indicating the month portion of the hospital confinement end date (the 'To' date).

Enter the date when the hospital confinement ended (or expected end date).

Check this box when you are indicating the day portion of the hospital confinement start date (the 'From' date).

Check this box when you are indicating the day portion of the hospital confinement end date (the 'To' date).

Briefly summarize the reason or circumstances for the hospital confinement (e.g., diagnosis, procedures, or clinical notes about the stay).

Enter the patient's primary ICD diagnostic code assigned by the physician (e.g., M54.5 or 401.9); this field is required.

If applicable, enter a secondary ICD diagnostic code assigned by the physician (e.g., M79.1); leave blank if there is no secondary diagnosis.

Enter a short, plain-language description of the primary diagnosis that corresponds to the primary ICD code (e.g., "Low back pain").

Enter a short, plain-language description of the secondary diagnosis that corresponds to the secondary ICD code, or leave blank if none.

Provide a clear, concise summary describing the circumstances of the disability (for example, details of the injury or how the illness occurred, work-related factors, timeline and relevant events) if the condition is work-related or injury-related. Fill only if 'Injury', 'Work Related' is 'Yes' (any).

Check this box if the disability was caused by an illness (non-traumatic medical condition) and you want it indicated as the circumstance for the claim.

Check this box if the disability was caused by a physical injury (traumatic event) and you want it indicated as the circumstance for the claim.

Check this box if the disability is related to the patient's work or occurred in the course of employment and you want it indicated as the circumstance for the claim.

Enter the primary administrative/footer code or reference number located at the very bottom-left of the form exactly as shown.

Enter the administrative/footer code or identifier printed in the lower-left footer area of the form exactly as shown.

Enter any additional details or clarifications about the patient’s functional limitations—especially regarding reaching (overhead, desk level, below waist) or related lifting/carrying activities—providing specifics about frequency, severity, and examples as needed.

Check this box to indicate the patient's frequency per day for standing when performing activities that involve lifting/carrying 1–5 lbs (mark N/O/F/C as appropriate).

Check this box to indicate the patient's frequency per day for overhead reaching when performing activities that involve lifting/carrying 1–5 lbs (mark N/O/F/C as appropriate).

Check this box to indicate the patient's frequency per day for desk-level reaching when performing activities that involve lifting/carrying 1–5 lbs (mark N/O/F/C as appropriate).

Check this box to indicate the patient's frequency per day for crouching when performing activities that involve lifting/carrying 1–5 lbs (mark N/O/F/C as appropriate).

Check this box if the patient can perform grasping tasks while lifting/carrying 6-10 pounds at the indicated frequency.

Check this box if the patient can perform crawling while lifting/carrying 6-10 pounds at the indicated frequency.

Check this box if the patient can perform walking while lifting/carrying 6-10 pounds at the indicated frequency.

Check this box if the patient can reach at level (waist/shoulder height) while handling 6-10 pounds at the indicated frequency.

Check this box if the patient can reach overhead while handling 6-10 pounds at the indicated frequency.

Check this box if the patient can grasp objects weighing 11–25 lbs at the indicated frequency per day.

Check this box if the patient can walk while lifting/carrying 11–25 lbs at the indicated frequency per day.

Check this box if the patient can sit while lifting/carrying 11–25 lbs at the indicated frequency per day.

Check this box if the patient can perform overhead reaching while handling 11–25 lb objects at the indicated frequency per day.

Check this box if the patient can perform reaching below waist level while handling 11–25 lb objects at the indicated frequency per day.

Check this box to indicate the patient can perform balancing while handling 26-50 lbs; record the frequency per day using the N/O/F/C scale.

Check this box to indicate the patient can perform pushing tasks involving 26-50 lbs; record the frequency per day using the N/O/F/C scale.

Check this box to indicate the patient can perform climbing while carrying or handling 26-50 lbs; record the frequency per day using the N/O/F/C scale.

Check this box to indicate the patient can reach below waist while handling 26-50 lbs; record the frequency per day using the N/O/F/C scale.

Check this box if the patient cannot stoop while lifting or carrying 51–100 pounds (i.e., has a limitation performing stooping with that weight).

Check this box if the patient cannot push objects weighing 51–100 pounds (i.e., has a limitation performing pushing with that weight).

Check this box if the patient cannot pull objects weighing 51–100 pounds (i.e., has a limitation performing pulling with that weight).

Check this box to indicate the patient's frequency of performing fingering while lifting/carrying 100+ lbs (record the frequency per day using the N/O/F/C code).

Check this box to indicate the patient's frequency of performing pulling while lifting/carrying 100+ lbs (record the frequency per day using the N/O/F/C code).

Check this box to indicate the patient's frequency of performing kneeling while lifting/carrying 100+ lbs (record the frequency per day using the N/O/F/C code).

Check this box to indicate the patient's frequency of performing bending while lifting/carrying 100+ lbs (record the frequency per day using the N/O/F/C code).

Enter the date of the most recent medical treatment the patient received for the condition.

Check this box when the date entered in the adjacent/above first date field is the patient's Initial Treatment date.

Check this box when the date entered in the adjacent/above second date field is the patient's Initial Treatment date.

Describe any workplace accommodations, modifications, or restrictions that would enable the patient to return to work safely.

List specific activities or actions the patient should avoid because of their condition (things the patient should not do).

Enter a concise summary of the patient’s overall limitations and restrictions related to their condition that affect normal activities or work.

Check this box when you are indicating the month portion of the patient's Most Recent Treatment date on the form.

Enter the date of the patient’s most recent treatment related to the claimed condition.

Check this box when you are indicating the day portion of the patient's Most Recent Treatment date on the form.

Enter the date of the patient's next scheduled treatment.

Check this box when entering the day component of the patient's Next Treatment date (use when the specific day of the next treatment is known).

Check this box when entering the year component of the patient's Next Treatment date (use when the specific year of the next treatment is known).

Provide detailed objective clinical findings related to the disability, including copies or summaries of any X‑rays, laboratory data, EKGs, MRIs, scans, and other diagnostic or clinical findings.

Enter the patient's weight, including units (for example, 150 lb or 68 kg).

Enter the patient's last (family) name or surname.

Enter the patient's blood pressure reading as systolic/diastolic (for example, 120/80).

Enter the patient's height, including units (for example, 5'10" or 178 cm).

Enter the patient's first (given) name as it appears on records.

Enter the patient's Social Security Number (include dashes if applicable).

Enter the name of the patient's employer or the company where they work.

Enter the patient's middle initial (single letter).

Enter the date the patient is expected to be able to return to full-time work (start of the date range).

Check this box to record the first (leftmost) digit of the four‑digit year for the date the patient is able to return to full‑time work (enter year digits left‑to‑right across the four boxes).

Check this box to record the second digit of the four‑digit year for the date the patient is able to return to full‑time work (enter year digits left‑to‑right across the four boxes).

Enter the date the patient is expected to be able to return to full-time work (end of the date range), if applicable.

Check this box to record the third digit of the four‑digit year for the date the patient is able to return to full‑time work (enter year digits left‑to‑right across the four boxes).

Check this box to record the fourth (rightmost) digit of the four‑digit year for the date the patient is able to return to full‑time work (enter year digits left‑to‑right across the four boxes).

Enter a brief description of how often the patient is receiving or should receive ongoing treatment (for example: 'weekly physical therapy', 'monthly injections', or 'daily home exercises').

Enter the city for the physician's practice or mailing address.

Enter the physician's city for their practice/address as it should appear on the form.

Enter the physician's state for their practice/address (use the two-letter abbreviation or full state name).

Enter the physician's postal ZIP code (include the 5-digit ZIP or ZIP+4, using a hyphen if applicable).

Enter the physician’s office fax number (include area code and any necessary punctuation or extension).

Enter the physician's full name (first name, middle initial if any, and last name) who completed this statement.

Enter the physician's office phone number (include area code and extension if applicable) as a single string.

Enter the physician’s full legal signature to attest to the information provided on this form.

Enter the date on which the physician signed this form.

Enter the physician's full street address (street number, street name, apartment or suite if applicable) as a single line.

Check this box to indicate the estimated delivery date (use the adjacent date boxes to record the full date).

Enter the date when the patient was first treated for this pregnancy.

Enter the estimated delivery date for the current pregnancy.

Check this box to indicate the actual date of delivery (use the adjacent date boxes to record the full date).

Enter the actual date on which the delivery occurred.

Check this box to indicate the actual date of delivery (use the adjacent date boxes to record the full date).

Check this box to indicate the 'First Treated' pregnancy date (use the adjacent date boxes to record the full date).

Check this box to indicate the estimated delivery date (use the adjacent date boxes to record the full date).

Check this box to indicate the 'First Treated' pregnancy date (use the adjacent date boxes to record the full date).

Check this box if the delivery was by cesarean section.

Check this box if the delivery was vaginal.

Enter a concise description of the patient’s prognosis for recovery, including expected outcome, anticipated timeline for improvement or return to function, and any factors that may affect recovery.

Check this box to indicate that the adjacent date is the date the patient's ability to work was reduced.

Enter the date on which the patient’s ability to work was first reduced.

Check this box to indicate that the adjacent date is the date the patient's ability to work was reduced.

Enter a detailed description of the patient's symptoms, including nature of symptoms, date/time of onset, severity, location, frequency, any aggravating or relieving factors, and how the symptoms have progressed or changed.

Enter the date when the patient's symptoms first began or were first noticed.

Check this box when you are indicating the date that the patient’s symptoms first appeared.

Check this box when you are indicating the date the patient’s ability to work was first reduced.

Describe the patient's current and recommended treatment plan, including medications, therapies, procedures, any completed or planned surgeries and relevant dates; include frequency or duration where applicable.

State how often the patient receives ongoing treatment, using words or numbers as needed (for example: daily, weekly, 2x/week, monthly) to clearly describe the frequency of care.