ATTENDING PHYSICIAN'S STATEMENT
(For Mental Health Claims)
Please fax the completed form to:
Fax Number: 8 33-357-5153
Lexington, KY 40512-4869
To Be Completed By The Employee
Date of Birth:
Insured ID Number:
Patient Address: (Street, City, State & Zip Code)
To be completed by the Provider - (The patient is responsible for the completion of this form without expense to
Is the condition related to environmental and/or interpersonal
issues in his/her workplace?
If "Yes," explain:
If yes, can he / she perform the same job at a different location / employer?
Are these issues causing a disincentive to return to work with current Employer?
DSM or ICD Code:
Secondary Condition: DSM or ICD Code:
Domain V Domain VI
Patient Assessment Measures
Other Assessment Measures - please list the measure scale and
provide score (attach test results):
Current Self Reported Symptoms
Current Observed Symptoms (Clinical presentation, frequency,
MENTAL STATUS EXAMINATION
(Please circle or check current status or explain in “Comments”)
Well groomed Disheveled
Cooperative Guarded Suspicious
Tangential Flight of ideas Circumst
Mood WNL Depressed Anxious Irritable Euphoric
Affect Congruent Incongruent Blunted Flat Labile
Insight into illness
Absent Fair Good
WNL Agitation Retardation
Please check the statement that
indicates how this was assessed?
Impaired: mild moderate
Impaired : mild
Indicate how this is a change from the patient's baseline. If the condition is chronic or long term, what and when did change occur?
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