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.
You can send these forms by fax or mail to the Great-West Life Disability Management Services Office nearest to where you live.
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 Great-West Life Disability Management Services Office nearest to where you live.
Cancer conditions - 1 mbpdf Opens in a new window
Cardiac conditions - these types of illnesses are also referred to as heart conditions. - 1 mbpdf Opens in a new window
Mental health conditions - 1 mbpdf Opens in a new window
Musculo-skeletal conditions - these conditions affect the functioning of your joints, tendons, ligaments and muscles. - 1 mbpdf Opens in a new window
Long term disability other conditions - this form can be used for all other medical conditions. - 1 mbpdf Opens in a new window
Short term disability and early referral services - this form can be used for all other medical conditions. - 169 kbpdf Opens in a new window
Print all condition forms - this PDF includes all of the condition forms. - 2 mbpdf Opens in a new window
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.