We need your permission to obtain information necessary to help us assess your claim. By signing this authorization request, you give Great-West Life permission to obtain information from your doctor, employer, other insurers and hospitals where you received treatment.
Print, read, complete and sign this form, then fax or mail it to the appropriate Disability Management Services Office. If you’re not sure which Disability Management Services Office to send your claim to, contact your plan administrator.
Attending physician’s statement
Print the statement that applies to you. Have your doctor complete and sign the form, and then fax or mail it to the appropriate Great-West Life Disability Management Services Office.
- Cancer conditions pdf
- Cardiac conditions - these types of illnesses are also referred to as heart conditions. pdf
- Mental health conditions pdf
- Musculo-skeletal conditions - these conditions affect the functioning of your joints, tendons, ligaments and muscles. pdf
- Long term disability other conditions - this form can be used for all other medical conditions. pdf
- Short term disability and early referral services - this form can be used for all other medical conditions. pdf
- Print all condition forms - this PDF includes all of the condition forms. pdf
Note: Any fees charged by your physician relating to the completion of claim reports including this Attending Physician’s Statement are your responsibility.
If you aren’t able to complete the entire form now, you can save it and finish it later. When the form is complete, save the final version and return here to submit it.
If you have any questions about submitting your document online, contact us at 1-855-755-6729
Prefer to send us a printed copy?
Print the completed Employee’s Statement and then fax or mail it to the appropriate Disability Management Services Office.