Insurance form
Long-Term Disability Medical Form
An LTD medical form asks whether the person meets that policy's definition of disability — usually inability to do their own occupation, then any occupation after a change of definition. You do not interpret the policy. You describe diagnoses, treatment, and the functional limits that would show up at work.
What LTD adjudicators read first
They look at last day worked, diagnosis, objective findings, current treatment, and the restriction table. A diagnosis of depression without hours, attendance, or cognitive limits is a delay. A completed restriction table with no diagnosis is also a delay.
Each carrier prints its own form. Sun Life, Manulife, Canada Life, Desjardins, and employer-specific PDFs are not interchangeable. Upload the one in the patient's portal or envelope.
Own occ vs any occ is their clause
If the form asks whether the person can do any job in the economy, answer from function, not from the booklet you have not read. If you only know they cannot do this job, say that and stop.
Who completes it
The most responsible treating clinician for the disabling condition. Mental-health LTD files often need the psychiatrist or psychologist who is actually treating, not only the family physician who refills an SSRI. If you are the FP and psychiatry is involved, complete your part and name them.
How to complete the clinical fields
- Primary diagnosis that stops work, and secondary conditions that add to the limit.
- Date first seen for this episode, date last worked, date you advised leaving work — three dates that should not contradict the employer form.
- Findings: PHQ/GAD or a mental-status example, joint measurements, exercise tolerance — whatever matches the disease.
- Treatment: drugs, doses, therapy frequency, specialist wait times. 'Follows with psychiatry' without a name or last visit is weak.
- Restrictions and limitations: sitting, standing, lifting, hours, concentration, public contact, safety-sensitive work. Use numbers.
- Prognosis for return: partial hours on a date, or not expected this year, with a review date.
- Gains if they tried modified work. Failed attempts are evidence. Hypotheticals are not.
Worked example (fictional)
Treatment-resistant depression — own occupation
Fictional 39-year-old. Do not copy into a real LTD form.
Primary: major depressive disorder, recurrent, currently severe, without psychosis. Onset this episode Dec 2025. Last worked 14 Jan 2026 (project manager, 45 h/week, deadline-driven). Findings last visit 21 Aug 2026: PHQ-9 21, slowed speech, cannot complete a 15-minute form without a break, two panic attacks in-store last month. No SI plan. Sleep 3–4 h. Treatment: venlafaxine 225 mg, mirtazapine 30 mg, weekly psychotherapy (started March), psychiatry consult June (Dr. Rao) — considering lithium augmentation. No ECT. R/L: cannot sustain 2 hours of concentrated desk work; no customer-facing; no safety-sensitive driving. Attendance would be unreliable most days. Tried 3 half-days in March — left each day by 10:30, performance errors. Not ready for modified hours now. Review Nov 2026 after augmentation trial. I am the FP; psychiatry is co-treating. I am not certifying 'any occupation.'
Why LTD medicals get independent exams
- Restrictions that do not match the diagnosis (total sit/stand/lift limits for a pure mood disorder with no MSK finding).
- No treatment despite 'total disability.'
- Dates that disagree with the employer.
- Copying last year's form with a new date.
- The FP certifying a condition only a specialist has ever described, without records.
Draft the LTD form from the visit
In Scribeberry, open Forms, search for the long-term disability medical form, or upload the carrier's current PDF. Generate from the encounter and your notes, then edit every field before you sign. Scribeberry does not pre-map this form. You still review and sign.
Frequently asked questions
Do I decide if the claim is approved?
No. You describe medical facts and function. The carrier applies the policy. Independent medical exams happen when the file is thin or inconsistent — not because you refused to tick 'totally disabled.'
What if I think the person can do another type of work?
Say so, with the limits that remain. Do not hide residual capacity. Do not invent a job in a field you know nothing about.
STD vs LTD — same form?
Often no. Short-term disability forms are shorter and employer-tied. Use the LTD PDF for LTD. Reusing STD answers without updating function is a common error at the change of definition.
Does Scribeberry submit the LTD form?
No. Scribeberry helps you complete the PDF. You or the patient return it to the carrier. Keep a copy in the chart.
Forms
