ATTENDING PHYSICIAN STATEMENT

BROADSPIRE – DISABILITY AND LEAVE MANAGEMENT

PO BOX 14773 Lexington, KY 40512
Toll Free US & Canada: 855-300-6712
Toll/Collect Outside US: 404-497-6869
FAX: 1-859-550-2744

EMPLOYEE INFORMATION
Section 1: Employee Information
EMPLOYEE NAME: Ines Kudo EMPLOYER NAME: World Bank Group
CLAIM NUMBER: C-2018-072828 EE ID: WBG00000247409 DATE OF BIRTH: 3/24/1976
JOB TITLE/DESCRIPTION: Senior Education Specialist

TO BE COMPLETED BY ATTENDING PHYSICIAN:

Section 2: Complete this Section for Pregnancy, then go to Section 4
Expected Delivery Date (mm/dd/yyyy): Actual Delivery Date (mm/dd/yyyy): Delivery Type: Date of first visit for this pregnancy Date Hospitalized (mm/dd/yyyy):
☐ Vaginal (mm/dd/yyyy):
☐ C-Section
Diagnosis: ICD Code: Did you advise your patient to cease working prior to If yes, what date? (mm/dd/yyyy):
delivery? ☐ YES ☐ NO

Were there any complications that caused your patient to cease working prior to the expected delivery date? ☐ YES ☐ NO
If yes, please provide explanation:

Section 3: Complete this section for all conditions except pregnancy, then go to Section 4
Primary Diagnosis: Primary ICD Code:

Secondary Diagnosis: Secondary ICD Code:

Please describe symptoms, including frequency, severity, and duration:

Date of first visit for the current condition(s) Date of last visit (mm/dd/yyyy): Date of next visit (mm/dd/yyyy): Frequency of treatment:
(mm/dd/yyyy): ☐ Weekly ☐ Monthly ☐ Other

Has the patient been treated for the same or If Yes, provide treatment dates: I he a ie c di i k ela ed? Did you advise the patient to stop working?
similar condition in the past? From: ☐ YES ☐ NO ☐ Unknown ☐ YES ☐ NO
☐ YES ☐ NO ☐ Unknown Through: If yes, date of incapacity:

Has the patient been hospitalized for this condition? Patients Height: Patients Weight:
☐ YES ☐ No
If Yes, provide date hospitalized: From: Through:
Was surgery performed? ☐ YES ☐ NO If Yes, what was the procedure? CPT Code: Date Surgery performed (mm/dd/yyyy):

Please describe your current treatment plan and include all medications with prescribed dosage:

Please comment on how cooperative and compliant the patient has been with current treatment plan:

C-2018-072828
ATTENDING PHYSICIAN STATEMENT
BROADSPIRE – DISABILITY AND LEAVE MANAGEMENT
PO BOX 14773 Lexington, KY 40512
Toll Free US & Canada: 855-300-6712
Toll/Collect Outside US: 404-497-6869
FAX: 1-859-550-2744

Additional Providers: Are you aware of or have you referred your patient to any additional treating providers? ☐ YES ☐ NO If Ye , lea e ide he ide ame
and contact information.
Name: Specialty: Address: Phone:

Has the patient been advised to return to work? What is the expected return to work date? (mm/dd/yyyy):
☐ YES ☐ NO
☐ Full Time ☐ Part Time Part Time hours per day:
How is your patient limited from performing his/her occupation and what prevents a return to work with full or partial duties?

What are the patients restrictions (what the patient should not do) and why?

What diagnostic tests or clinical exam findings support your patients work restrictions and limitations? Please include results of any examination, lab data, x -rays, EKGs, and MRI:
For behavioral health claims, please document results of a mental status exam or provide behavioral observations which cont ain evidence of impaired functioning.

Are there any non-medical factors which have a significant impact on functional abilities? (Please consider the following: Work place issues (ie problems with supervisor, performance);
Social/Family issues; Alcohol/Drug abuse; Financial/Legal issues)

Section 4: Physical Capabilities:

(1) Pa ie abili : (2) Pa ie abili : (ci cle)
Hours (circle) (check) Climb Yes No
Sit 1 2 3 4 5 6 7 8 ☐ Continuously ☐ Intermittently Twist/bend/stoop Yes No
Stand 1 2 3 4 5 6 7 8 ☐ Continuously ☐ Intermittently Reach above shoulder level Yes No
Walk 1 2 3 4 5 6 7 8 ☐ Continuously ☐ Intermittently Operate a motor vehicle Yes No

(3) Pa ie abili lif /ca : (check) (4) Pa ie abili e f m e e i i el : (ci cle)

Never Occasionally Frequently Continuously
0% 1-35% 36-66% 67-100% Right Hand Left Hand
Up to 10 lbs. ☐ ☐ ☐ ☐ Fine finger movements Yes No Yes No
11 to 20 lbs. ☐ ☐ ☐ ☐ Eye/hand movements Yes No Yes No
21 to 50 lbs. ☐ ☐ ☐ ☐ Pushing/pulling Yes No Yes No
51 to 100 lbs. ☐ ☐ ☐ ☐
Over 100 lbs. ☐ ☐ ☐ ☐ Dominant Hand Right Left
Section 5: Psychological Functions: ONLY COMPLETE SECTION 5 & 6 FOR CLAIMS WHICH INVOLVE A MENTAL
HEALTH CONDITION
Check Applicable box below:
C-2018-072828
ATTENDING PHYSICIAN STATEMENT
BROADSPIRE – DISABILITY AND LEAVE MANAGEMENT
PO BOX 14773 Lexington, KY 40512
Toll Free US & Canada: 855-300-6712
Toll/Collect Outside US: 404-497-6869
FAX: 1-859-550-2744
☐ Class 1 Patient is able to function under stress and engage in interpersonal relations (no limitations)
☐ Class 2 Patient is able to function in most stress situations and engage in some interpersonal relations (slight limitations)
☐ Class 3 Patient is able to engage in only limited stress situations and engage in only limited interpersonal relations (moderate limi tations)
☐ Class 4 Patient is unable to engage in stress situations and engage in interpersonal relations (marked limitations)
☐ Class 5 Patient has significant loss of psychological, physiological, personal, and social adjustment (severe limitations)
Remarks:

Wha e fac blem ihi e e al kill ha e affec ed a ie abili perform the duties of his or her job?

Is patient competent to endorse checks and direct use of proceeds? ☐ Yes ☐ No

Section 6: Exam Findings for Behavior Health Diagnosis

1. Presented with appropriate dress and hygiene in session? ☐ YES ☐ NO Please describe:________________________________________________

2. Psychomotor activity and ability to put forth effort? ☐ Unremarkable ☐ Impaired Please describe:__________________________________________

3. Speech: ☐ Spontaneous ☐ Pressured ☐ Stammering ☐ Slurred ☐ Loud ☐ Soft ☐ Tangential ☐ Over productive ☐ Under productive

4. Affect: ☐ Congruent ☐ Inappropriate ☐ Blunted ☐ Restricted ☐ Flat ☐ Labile

5. Mood: ☐ Euthymic ☐ Angry ☐ Euphoric ☐ Apathetic ☐ Dysphoric ☐ Apprehensive

6. Able to spontaneously compose her/himself? ☐ YES ☐ NO Please explain:______________________________________________________________

7. Panic Attacks? ☐ YES ☐ NO If Yes, Please specify below:

a. Frequency of panic attacks_______________________________________
b. Duration of panic attacks_________________________________________
c. Symptoms experienced__________________________________________

8. Reasoning and/ or Judgment: ☐ Within normal limits ☐ Impaired Please explain:____________________________ __________________________________

9. Demonstrates ability to concentrate for: ☐ less than 5 min. ☐ 5-10 min. ☐ 15-30 min. ☐ 30-50 min.

10. Able e f m fi e e ai f e ial 7 3 ? ☐ Yes ☐ No exam findings__________________________________________________________________

11. Hallucinations or Delusions reported? ☐ YES ☐ NO If Yes, Please describe__________________________________________________________________

12. Risk to self/others: Suicidal Ideations? ☐ YES ☐ NO If Yes, Please describe if plan reported ____________________________________________________
Homicidal Ideations? ☐ YES ☐ NO If Yes, Please describe if plan reported ____________________________________________________
Has employee contracted for safety? ☐ YES ☐ NO If no, Please describe ____________________________________________________
Is employee able to provide reasons for not hurting self/others? ☐ YES ☐ NO If no, Please describe _______________________________

13. Any other notable behaviors observed during exam_________________________________________________________________________________________

14. Is employee currently performing: ☐ work at lesser demanding job ☐ attending school ☐ Self- employed ☐ Volunteer work ☐ No work activities in any capacity

Please include any progress notes with observable psychological examination findings from mental health exam.
Thank you.

C-2018-072828
ATTENDING PHYSICIAN STATEMENT
BROADSPIRE – DISABILITY AND LEAVE MANAGEMENT
PO BOX 14773 Lexington, KY 40512
Toll Free US & Canada: 855-300-6712
Toll/Collect Outside US: 404-497-6869
FAX: 1-859-550-2744
Section 7: Attending Physician Signature:
Physician Name (Last Name, First, MI, Suffix) Please Print: Specialty/Degree:

Address:

City: State: Zip:

Telephone Number: Fax Number: Physician Tax Id Number: Are you related to this patient? ☐ YES ☐ NO
If yes, describe relationship:

I certify that the above statements are true and accurate to the best of my knowledge and belief.

Signature: Date:

The Genetic Information Non-Discrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requirin g genetic information of an
individual or family member of the individual, except as specifically allowed by law. To comply with this law, we are asking, that you not provide any genetic information when responding
to this request for medical information. Genetic inf a i a defi ed b GINA, i cl de a i di id al fa il edical hi , he e l f a i di id al fa il e be ge e ic
e , he fac ha a i di id al a i di id al fa il e be gh ecei ed ge e ic e ice , a d ge e ic i f a i f a fe ca ied b a i di id al fa il e be a
embryo lawfully held by an individual or family member receiving assistive reproductive services.

Fraud Warning:
APPLICABLE WORLD BANK GROUP STAFF RULES
Any mis-statements made in this claim application may result in disciplinary measures, per Staff Rule 8.01, which may include criminal or civil penalties.

C-2018-072828