An Attending Physician Statement (APS) should include the medical and administrative information requested by the specific form, which may cover diagnoses, symptoms, treatment, medications, diagnostic findings, medical history, functional limitations, prognosis, and other relevant medical information. The specific information included in an APS depends on the insurance request, the purpose of the statement, and what the requesting organization needs to know.
Reviewing the form and its instructions can help identify the sections that need to be addressed and any details that may require clarification or supporting records.
This blog explains the key components commonly found in an Attending Physician Statement, how to check an APS for completeness and when additional medical records may be needed.
What Is an Attending Physician Statement?
An Attending Physician Statement is a medical statement completed by a treating or attending physician in response to questions from an insurer or other requesting organization. It provides information about the patient’s medical history, condition, treatment, and clinical status based on the physician’s knowledge and medical records.
An APS may be requested for:
- Insurance underwriting and policy eligibility review
- Disability-related assessments
- Claims-related evaluations
- Other situations requiring treating physician information
The form may ask about a particular condition or request information covering a broader period of medical history. Because APS forms can differ in their questions and instructions, the information required should be assessed based on the form being reviewed rather than a universal checklist.
Before concluding that information is missing, reviewers should check the unanswered item against the form's questions and instructions and determine whether clarification or additional records are needed.
Attending Physician Statement Checklist: 12 Key Components
An APS should clearly cover the medical information requested on the form, including relevant diagnoses, symptoms, treatment, medications, test findings, and functional limitations.
The checklist below highlights 12 key areas to review for clear and complete documentation.
- Patient Information
The APS generally begins with basic information that identifies the patient and connects the statement to the appropriate insurance request.
This may include:
- Patient’s full name
- Date of birth
- Policy or application information
- Relevant identification details
Reviewers should compare the patient information on the APS with the original request and note any differences that may need clarification.
- Physician and Medical Provider Information
An APS typically provides information about the physician or healthcare provider who completes the statement.
Depending on the form, this may include:
- Physician name
- Medical specialty
- Practice or facility name
- Address and contact information
- Relationship to the patient
- Relevant provider identification information
This information provides context about who supplied the medical information and allows the requesting organization to identify the source if clarification is needed.
The exact credentials or identification numbers required will depend on the form. Reviewers should follow the specific instructions rather than assume that every APS requires the same provider information.
- Diagnoses and Medical Conditions
The APS may include relevant diagnoses and medical conditions documented by the physician.
Information may include:
- Diagnosis or condition
- Date or period when it was documented, where available
- Current or historical status, where documented
- Related complications
- Associated conditions
- Relevant changes in the condition
The focus should be on the conditions relevant to the questions being answered. An APS does not necessarily need to reproduce every diagnosis contained in a patient's complete medical record.
It is also important to distinguish a documented diagnosis from conclusions about its cause, severity, or future course. Those conclusions should be supported by the medical documentation and the physician's stated assessment.
- Symptoms and Clinical Complaints
An APS may describe symptoms or complaints associated with a documented condition.
Depending on the form, relevant information may include:
- Type of symptom
- Onset
- Duration
- Frequency
- Severity, where documented
- Changes in symptoms
- Related complaints
The statement should distinguish between information reported by the patient and findings documented by the physician when the distinction is relevant.
- Treatment History
Treatment history describes how a documented condition has been managed.
An APS may include:
- Procedures
- Surgery
- Physical or other therapy
- Specialist referrals
- Other relevant treatment
- Treatment dates or duration, where available
- Changes in treatment
The level of detail depends on the questions asked on the form.
When treatment has changed, the APS may provide the reason for the change if the physician has documented it and the form calls for that information. A change in treatment should not automatically be interpreted as evidence that a condition improved or worsened.
- Diagnostic Tests and Findings
An APS may include information about diagnostic tests and their findings when those details are relevant to the questions being answered.
These may include:
- Laboratory testing
- Imaging studies
- Diagnostic procedures
- Other diagnostic studies
- Test dates
- Reported findings
- Follow-up testing
- Physician interpretation, where included
A brief reference to a test in an APS may not provide the full findings contained in the original report. When a result is important to the review, the underlying report may provide additional context.
- Medications
Medication information may be documented separately depending on the questions included in the APS.
Depending on the form, an APS may include:
- Medication name
- Dosage
- Frequency
- Reason for use, where documented
- Start or stop dates, where available
- Medication changes
- Reported adverse effects or intolerance, where relevant
The medication list should reflect the information available to the physician when the APS is completed.
- Functional Limitations and Restrictions
Some APS forms ask the physician to describe how a medical condition affects the patient's physical or functional abilities.
Depending on the purpose of the APS, this may include:
- Physical restrictions
- Ability to perform specific activities
- Work-related limitations
- Sitting, standing, walking, or lifting restrictions
- Cognitive limitations when relevant
- Activities of daily living
- Expected duration of restrictions
Functional information is particularly relevant to disability-related requests. It may be less prominent in APS forms designed for other insurance purposes.
- Prognosis and Expected Course
Some APS forms request the physician's documentation regarding the expected course of the condition.
Depending on the form, this may include:
- Expected recovery
- Anticipated improvement
- Ongoing limitations
- Expected treatment
- Follow-up plans
- Long-term considerations
The prognosis should reflect the physician's documented clinical assessment rather than assumptions made by someone reviewing the form.
- Relevant Medical History
An APS may include previous medical information that provides context for the condition or questions being addressed.
This may include:
- Previous medical conditions
- Earlier symptoms
- Prior treatment
- Previous surgeries
- Prior hospitalizations
- Chronic conditions
- Significant medical events
The purpose is not necessarily to reproduce the patient's entire medical history. Relevant history should provide context for the medical information requested.
- Supporting Records or Referenced Information
An APS may refer to information contained in other medical records.
These references may include:
- Laboratory reports
- Imaging reports
- Pathology reports
- Hospital records
- Specialist records
- Records from other treating providers
- Other supporting documentation
A reference to another record does not necessarily mean that the record is included with the APS. When additional context is needed, the referenced record may need to be reviewed separately.
- Physician Certification and Signature
The APS may require the physician to confirm completion of the statement.
This may include:
- Physician's signature
- Date of completion
- Professional credentials, where required
- Practice information, where required
- Certification statements required by the insurer
The exact certification requirements depend on the APS form and requesting organization.
How Can You Check an APS for Completeness?
A completed APS can be checked against the specific form and its instructions to identify missing or unclear information.
A practical review can follow these steps.
- Review the requested information
Confirm that the APS addresses the questions relevant to the purpose of the request.
Make sure applicable fields and questions are completed according to the form's instructions.
- Verify dates and time periods
Check that required dates and relevant time periods are provided where applicable.
- Review referenced records
Determine whether any documents or medical records referenced in the APS need to be reviewed separately.
- Flag missing or unclear information
Identify unanswered questions, inconsistencies, or details that may require clarification.
How Can LezDo TechMed Simplify APS Review?
Reviewing an APS may require information to be checked against supporting medical records. LezDo TechMed's APS summary services organize relevant information from the APS and associated records into a structured format for review.
The summary brings related medical information together and helps reviewers trace key details back to available supporting documentation when additional context is needed.
The original APS and supporting medical records remain available for verification when a reviewer needs to examine the underlying information in greater detail.
Conclusion
An Attending Physician Statement should be reviewed according to the purpose of the request and the questions included in the form. A checklist provides a practical way to assess whether the relevant questions have been answered and whether any part of the statement needs clarification.
However, an APS should not be treated as a replacement for the complete medical record. When information is unclear, incomplete or referenced but not included, the supporting documentation may be needed to understand the circumstances more fully.
A careful APS review should distinguish documented medical information from interpretation. When the statement does not provide enough detail, the supporting medical records can be reviewed rather than making assumptions from the APS alone.
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