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Sheet: Sheet1

 |  |  |  | Disability Claim Attending Physician Statement
 | Colville Confederated Tribes Human Resources Office, PO Box 150 Nespelem, WA 99155 P: (509) 634-2842   F: (509) 634-2722
Instructions: 1 )Complete all applicable areas of this claim form 2) Sign the claim form 3) Fax this form to expedite your claim - retain original for your records
The following section must be completed and signed by the employee/patient. |  |  |  |  |  | Occupation:
Any fee for the completion of this form is the patients responsibility.
Name: |  |  |  | SSN: |  | Employer:
I hereby authorize my physician to release any information acquired in the course of examination or treatment |  |  |  |  |  |  |  | DOB:
Signature of Employee: |  |  |  |  | Date:
The following section must be completed and signed by the attending physician. The purpose of this report is to assist us in making a disability determination
Please complete all applicable sections of this form. A Colville Confederated Tribes Human Resource office representative may telephone your office if additional information needed
 | History |  | Diagnosis & Treatment |  |  | Psychological Functions |  |  | Physical Capabilities
Symptoms results from: (Circle one) |  |  | Primary ICD-9 |  |  | Circle the appropriate box below |  |  | A) Patient's ability to: (circle)
Injury |  |  | Diagnosis |  |  | Class 1 |  |  | Hours
Illness |  |  |  |  |  |  |  |  | Sit         0 1 2 3 4 5 6 7 8
Pregnancy |  |  |  |  |  |  |  |  | Continuously   Intermittently
Due Date: | Expected: |  |  |  |  |  |  |  | Stand    0 1 2 3 4 5 6 7 8
 | Actual: |  | Secondary ICD-9 |  |  |  |  |  | Continuously   Intermittently
Type of delivery? |  |  | Diagnosis |  |  | Class 2 - |  |  | Walk     0 1 2 3 4 5 6 7 8
Is condition work related? |  | Circle one |  |  |  |  |  |  | Continuously   Intermittently
YES    NO |  |  |  |  |  |  |  |  | B) Patients ability to: (circle)
Initial date of service: |  |  | Subjective Symptoms: |  |  |  |  |  | Climb | Yes    No
Most recent treatment date: |  |  |  |  |  |  |  |  | Twist/Bend/stoop | Yes    No
Did you advise the patient to cease the |  |  | Objective findings (include copies/results |  |  |  |  |  | Reach above shoulder level
above occupation? |  | YES      NO | of any x-rays, lab tests, EGS's, MRI's, |  |  | Class 3- |  |  | L      R | Yes    No
 | If yes date: |  | scans, and office notes.) |  |  |  |  |  | Operate Motor Vehicle     Yes   No
Names and phone numbers of the other |  |  |  |  |  |  |  |  | C) Patients ability to lift/carry:
providers the patient is/was referred to: |  |  |  |  |  |  |  |  | 10-20lbs:  pOccasionally (1-35%)
Name: |  |  | Current and recommended treatment plans |  |  |  |  |  | pFrequently (36-66%)
Phone: |  |  |  |  |  | Class 4 - |  |  | pContinuously (67-100%)
Name: |  |  | If surgery is performed, provide the following |  |  |  |  |  | 21-50lbs:  pOccasionally (1-35%)
Phone: |  |  | [NAME]: |  |  |  |  |  | pFrequently (36-66%)
Has patient been hospitalized? |  |  | Prodecure: |  |  |  |  |  | pContinuously (67-100%)
Yes Date: |  | Thru: | Date: |  |  | Class 5 - |  |  | 51-100lbs: pOccasionally (1-35%)
No |  |  | Medications prescribes (names & dosages) |  |  |  |  |  | pFrequently (36-66%)
Name & Address of facility |  |  |  |  |  |  |  |  | pContinuously (67-100%)
Name: |  |  |  |  |  |  |  |  | 101lbs+: pOccasionally (1-35%)
Address: |  |  |  |  |  |  |  |  | pNever  pFrequently (36-66%)
Cardiac |  |  |  |  |  |  |  |  | pContinuously (67-100%)
Functional Capacity (American Heart Association) Complete only if applicable |  |  |  |  |  |  |  |  | D) Patients ability to perform
Class 1 (No Limitation)    Class 2 (Slight Limitation)   Class 3 (Marked Limitation)    Class 4 (Complete Limitation) |  |  |  |  |  |  |  |  | repetitive movement
Blood pressure (Latest reading) |  |  | / | as of (date) |  |  |  |  | Fine finger movements | Yes    No
Is the patient in a cardiac rehabilitation program? |  |  |  |  |  |  |  |  | Eye/hand movements | Yes    No
Prognosis |  |  |  | Rehab |  |  |  |  | Pushing/pulling | Yes    No
Have you advised the patient to return to work? |  |  |  | Do you suggest that the patient become involved in any of the following? |  |  |  |  | Dominant Hand | L        R
p Yes    If yes, date of return: ___/___ |  |  |  | (Please circle as many as apply) |  |  |  |  | F) Patient can work a total of
To regular occupation         Full time      Part time |  |  |  | Physical Therapy |  | Job Modification |  |  |  | hrs per day
To any other occupation     Full time    Part time |  |  |  | Occupational Therapy |  | Voc Rehab |  |  | G) Do you expect improvement in
p No        If not, please explain: |  |  |  | Cardiac Rehabilitation |  | Psychological Counseling |  |  | any area? (If so, please comment
Any work/activity restrictions (please be specific) |  |  |  | Pain Management Program |  | Other: |  |  | and dates/timeframes):
 |  |  |  | If so, was this discussed with the patient? |  |  | Yes         No
Physician | Name: |  |  |  | Degree/Specialty:
Street Address: |  |  |  |  | City: |  | State: |  | Zip:
Phone #: | (           ) |  |  |  | Fax #: |  |  | Tax ID #:
Contact person if additional information is necessary:
Signature: |  |  |  |  | Date: