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Physician Statement Form Template

Streamline medical documentation with our physician statement template

Creating a thorough physician statement can be overwhelming when your focus should be on patient care. This template is designed for healthcare professionals who need to efficiently document medical conditions, treatment plans, and diagnoses. With it, you can ensure clarity in patient records, save time on paperwork, and improve communication with insurance providers. Whether you're a doctor needing to submit information for claims, or a medical office improving workflow, this form helps maintain accurate documentation. Explore the template to see how it can simplify your process today.

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Patient full name
Date of birth
Patient phone number
Patient email address
Employer or school name
Physician full name
Medical license number
Specialty
Practice phone number
Practice address
Date of examination
Primary diagnosis or condition (include brief clinical findings as needed)
Condition type
Acute
Chronic
Intermittent
Undetermined
Approximate onset date of condition or symptoms
Patient is currently under your care for this condition
Yes
No
Functional areas currently limited (select all that apply)
Please Specify:
Current work or school capacity
Full duty without restrictions
Full duty with restrictions
Light/modified duty
Not able to work or attend school
Expected duration of the above limitations
Less than 1 week
1-4 weeks
1-3 months
3-6 months
More than 6 months
Undetermined
Treatments provided or planned (select all that apply)
Please Specify:
Maximum work or class hours per day
No work
Up to 2 hours per day
Up to 4 hours per day
Up to 6 hours per day
Full-time as tolerated
Not applicable
Lifting/carrying limit
No lifting
Up to 5 lb / 2 kg
Up to 10 lb / 5 kg
Up to 20 lb / 9 kg
Up to 50 lb / 23 kg
No restriction
Not applicable
Additional restrictions (select all that apply)
Is leave from work or school recommended?
Yes
No
Estimated leave start date (if applicable)
Estimated return-to-duty date (if applicable)
Recommended accommodations (select all that apply)
I authorize the release of this physician statement to my employer/school or their representative for the purpose of leave, accommodation, or benefits administration
Yes
No
Name of patient or legal guardian (typed full name serves as signature)
Authorization date
Physician name (typed full name serves as signature)
Certification date
I certify that the information provided above is accurate to the best of my knowledge and based on a clinically appropriate evaluation
True
False
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Paper art illustration featuring a physician statement form template with a modern design and clean layout

When to use this form

Use this template when an insurer, employer, or school requests a signed medical summary from a licensed clinician. It works for short-term disability claims, FMLA leave, post-op work restrictions, workers comp, or return-to-duty clearances. You capture diagnosis, objective findings, functional limits, and a timeline, so reviewers can make fast, defensible decisions. For cardiac or hypertension cases, attach readings from the Blood pressure monitoring form. For concussion, stroke, or neuropathy, reference results from the Neurological exam form. The result is a clear, standardized statement that reduces back-and-forth, protects patient privacy, and speeds approvals.

Must Ask Physician Statement Questions

  1. What is the primary diagnosis, onset date, and current status?

    This pins the statement to a clear condition and timeline, which reviewers need to assess eligibility. It also shows whether the issue is acute, chronic, or resolved.

  2. What objective findings support this condition (vitals, tests, imaging)?

    Concrete data boosts credibility and reduces follow-up calls. If helpful, add patient-reported trends from the Self-health assessment form to give context.

  3. What functional limitations and specific work or school restrictions apply?

    Translating symptoms into restrictions guides accommodations and risk control. Be precise, such as no lifting over 20 lb, no night shifts, or limited screen time.

  4. What treatments, medications, and follow-up plan are in place?

    A clear care plan shows next steps and expected response. You can organize tests and referrals using the Clinical assessment form.

  5. What is the prognosis and expected return-to-activity or reevaluation date?

    Approvers rely on this date to set benefits, schedules, and check-ins. If uncertain, provide a timeframe window and the clinical trigger for re-review.

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