Tip for Insurer-specific APS

Schedule a dedicated appointment with your doctor to complete this form thoroughly

Tip for Insurer-specific APS

Ask your doctor to include specific functional limitations (lifting, sitting, standing, concentrating)

Tip for Insurer-specific APS

A well-completed APS is often the single most important document in a disability claim

Social Security DisabilityhardDoctor signature required

Attending Physician Statement (APS)

Insurer-specific APS · Disability Insurance Carriers

Physician's report on diagnosis, symptoms, functional limitations, treatment plan, prognosis, and estimated return-to-work date. Requested at initial claim and periodically.

Form Details

Total fields: 55
Auto-fillable: 40 (73%)
Time without BeneFill: 45 minutes
Time with BeneFill: 12 minutes
Time saved: 33 minutes
Filled by: doctor
Frequency: per incident

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Where to Submit This Form

📬

Return to the insurance carrier or agency that sent it

Provide to your treating physician for completion, then return to the requesting party.

📠

Fax to the insurance carrier

Fax number is typically on the form or accompanying letter.

Required Attachments

📎 Must be completed and signed by the treating physician
📎 Relevant medical records, test results, and imaging
📎 Treatment plan and prognosis

Processing Time

Part of the disability claim process — typically reviewed within 2-4 weeks of receipt.

What Happens Next

The insurance carrier or SSA will use the physician's assessment in making the disability determination. Additional information may be requested.

Tips for This Form

✓ Schedule a dedicated appointment with your doctor to complete this form thoroughly
✓ Ask your doctor to include specific functional limitations (lifting, sitting, standing, concentrating)
✓ A well-completed APS is often the single most important document in a disability claim

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Adult Disability Report

SSA-3368-BK · SSA

The most complex patient-facing disability form. 15 pages requiring complete medical history, all diagnoses, medications, treating providers, hospitalizations, and work history.

Work History Report

SSA-3369-BK · SSA

10-page report requiring detailed descriptions of all jobs held in the past 15 years including physical demands, tools used, supervision, and lifting requirements.

Function Report

SSA-3373-BK · SSA

10-page functional assessment covering ADL capacity, daily routines, social functioning, cognitive abilities, and physical limitations.

Authorization to Disclose Information

SSA-827 · SSA

Authorization allowing SSA to collect medical and other information from providers, hospitals, and other sources for disability determination.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Disability Insurance Carriers or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.