Disability Attending Physician Statement
The Lincoln National Life Insurance Company
PO Box 2609 Omaha, NE 68103-2609
Toll Free (800) 423-2765 Fax (877) 843-3950
LincolnFinancial.com
[email protected]Instructions: All sections below need to be completed by your treating provider. Once complete login to our secure portal to
upload the document, fax to (877) 843-3950, or email to [email protected].
1. Claimant Information
Employee’s Name: Claim Number:
Date of Birth: Telephone Number: Social Security Number:
Employer Name:
2. Medical Facts
Primary Diagnosis: _____________________________________________________ ICD-10 Code: ___________________
Secondary Diagnosis: __________________________________________________ ICD-10 Code: ___________________
Co-Morbids:___________________________________________________________________________________________
Height: ______________________ Weight: _______________________ Gender: ________________________________
Is the Disability a Result of: h Illness h Injury h Work Related
Date Unable to Work:______________________________ If Injury, Date of Injury:________________________________
Date of Initial Treatment: ___________________________ Date of Most Recent Treatment: ________________________
Date of Next Treatment: ___________________________ Reoccurring Condition? h Yes h No
Has Patient Been Hospitalized: h Yes h No If Yes, Dates of Admission and Discharge: to
Hospitalization Reason: _______________________________________________________________________________
Has/Will Surgery Occur? h Yes h No Surgery Elective? h Yes h No Date of Surgery:_________________
Surgery Type:________________________________________________________________________________________
If Pregnancy: Estimated Due Date: _________________________ Actual Delivery Date: ___________________________
Advised to Cease Work Prior to Delivery: h Yes h No Delivery Type: h Vaginal h C-Section
Pregnancy Complications:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Symptoms (including impact to ADL’s, and self reported symptoms):
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Objective Findings (include copies of x-rays, EKG’s, blood work, scans, and any clinical findings):
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 1 of 4
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Nature of Treatment (current and recommended, frequency) and Treatment/Physician Referrals (include phone/fax number):
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Medications (include dosage, frequency, and dates prescribed/changed):
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Restrictions and Limitations:
Physical Diagnosis: Mental Diagnosis (Ability to perform task using scale below):
Lifting: _______ lbs _______ hours per work day 1 = Unable to Perform 2 = Markedly Limited
Carrying: _______ lbs _______ hours per work day 3 = Somewhat Limited 4 = Unlimited
Perform at Constant Pace: ____________________
Provide Hours per Work Day:
Maintain Attention/Concentration: ____________________
Sitting: _________________ Comprehend Daily Tasks: ____________________
Standing: _________________ Multi-Task: ____________________
Walking: _________________ Communicate Effectively: ____________________
Kneeling: _________________ Regulate EmotIons: ____________________
Climbing: _________________ Follow Instructions: ____________________
Squatting: _________________ Interact with Colleagues: ____________________
Stooping: _________________ Interact with Public: ____________________
Bending: _________________ Make Decisions: ____________________
Reaching: _________________ Work Alone/Separate from Others: ____________________
Dates of Restrictions and Limitations: ______________ to ______________ Date Able to Return to Work:______________
h Full Time h Part Time Part Time Days/Hours: ______________________________________________________
Job Modifications Needed to Return to Work:
Modified Work Schedule: ___________________________________ Duration of Modified Work Schedule: ______________
Additional Restrictions and Limitations:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
3. Signature
New York. Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subject to a civil penalty not to
exceed five thousand dollars and the stated value of the claim for each such violation.
Printed Name of Provider (including Credentials):______________________________________________________________
__________________________________________________________________ ________________________________
Provider Signature Date
Specialty of Practice: ____________________________ Address of Practice: _______________________________________
Phone Number: ________________________________ Fax Number: _____________________________________________
Email: ________________________________________________________________________________________________
Lincoln Financial Group is not responsible for charges incurred due to completion of this form. The patient is responsible for any
charges associated with form completion. Please see Fraud Notices attached.
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FRAUD NOTICES. For your protection, certain states require that the following notices appear on
this form.
Alabama. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit
or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
Alaska. A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a
claim containing false, incomplete or misleading information may be prosecuted under state law.
Arizona. For your protection Arizona law requires the following statement to appear on this form. Any
person who knowingly presents a false claim for payment of a loss is subject to criminal and civil penalties.
Arkansas, Louisiana, Rhode Island and West Virginia. Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to fines and confinement in prison.
California. For your protection California law requires the following to appear on this form: Any person who
knowingly presents a false or fraudulent information to obtain or amend insurance coverage or to make a claim
for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Colorado. It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an
insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of
an insurance company who knowingly provides false, incomplete, or misleading facts or information to a
policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant
with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado
Division of Insurance within the Department of Regulatory Services.
Delaware. Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a
statement of claim containing any false, incomplete or misleading information is guilty of a felony.
District of Columbia. It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer
may deny insurance benefits, if false information materially related to a claim was provided by the applicant.
Florida. Any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a statement
of claim, or an application containing any false, incomplete, or misleading information is guilty of a felony of
the third degree.
Kansas. A person may be guilty of fraud as determined by a court of law, if he or she submits an application
or claim containing a false or deceptive statement with intent to defraud (or knowing that he or she is helping
to defraud) an insurance company.
Kentucky. Any person who knowingly and with the intent to defraud an insurance company or other person
files a statement of claim containing any materially false information or conceals, for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.
Maine. It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company
for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance
benefits.
Maryland. Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss
or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of
a crime and may be subject to fines and confinement in prison.
New Jersey. Any person who knowingly files a statement of claim containing any false or misleading
information is subject to criminal and civil penalties.
New Mexico. Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or knowingly presents false information in an application for insurance is guilty of a crime and may
be subject to civil fines and criminal penalties.
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North Carolina. Any person who, with intent to injure, defraud, or deceive an insurer or insurance claimant:
(1) presents or causes to be presented a written or oral statement, including computer-generated documents
as part of, in support of, or in opposition to, a claim for payment or other benefit pursuant to an insurance
policy, knowing that the statement contains false or misleading information concerning any fact or matter
material to a claim, or (2) assists, abets, solicits, or conspires with another person to prepare or make any
written or oral statement that is intended to be presented to an insurer or insurance claimant in connection
with, in support of, or in opposition to, a claim for payment or other benefit pursuant to an insurance policy,
knowing that the statement contains false or misleading information concerning a fact or matter material to
the claim is guilty of a Class H felony.
Ohio. Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer,
submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma. Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any
claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is
guilty of a felony.
Oregon. A person may be committing insurance fraud, if he or she submits an application or claim containing
a misstatement, misrepresentation, omission or concealment with intent to defraud (or knowing that he or
she is helping to defraud) an insurance company.
Pennsylvania. Any person who knowingly and with intent to defraud any insurance company or other person
files an application for insurance or statement of claim containing any materially false information or conceals
for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance
act, which is a crime and subjects such person to criminal civil penalties.
Puerto Rico. Any person who knowingly and with the intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment
of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a
felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand
dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three
(3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established
may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be
reduced to a minimum of two (2) years.
Tennessee, Virginia, and Washington. It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of defrauding the company. Penalties include
imprisonment, fines and denial of insurance benefits.
Texas. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of
a crime and may be subject to fines and confinement in state prison.
Vermont. Any person who knowingly presents a false statement in an application for insurance may be
guilty of a criminal offense and subject to penalties under state law.
FOR ALL OTHER STATES. A person may be committing insurance fraud, if he or she submits an application
or claim containing a false or deceptive statement with intent to defraud (or knowing that he or she is helping
to defraud) an insurance company.
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