REQUIRED information in case pages get separated: Claimant First Name Middle Name Last Name Claim Number SECTION 2: Information About Your Patient's Health (To be completed by the physician providing treatment for the disability condition.) • Please provide all applicable information requested about your patient. The information you share will be used in making a decision about your patient's claim for disability benefits. • After you complete this form, please submit it along with office notes and results from any diagnostic testing related to your patient's condition (e.g., x-ray, lab tests, EKG or MRI). See Section 4 below for instructions on how to submit this completed form and any supporting documents to MetLife Disability. History Of Your Patient's Condition First date of treatment for this condition (mm/dd/yyyy) Most recent date of treatment (mm/dd/yyyy) What is the cause of your patient's symptoms? (Check one) Injury Illness Pregnancy (Type of birth - Check one below) Cesarean Natural Birth Not yet delivered: Expected delivery date (mm/dd/yyyy) List any other physicians or specialists you referred your patient to: First name Last name Specialty Phone number Is your patient's condition work-related? Yes No Did you advise your patient to stop working? Yes On date (mm/dd/yyyy) No Has your patient been hospitalized for this condition? Yes On date (mm/dd/yyyy) No Facility Name Address City State ZIP About The Diagnosis And Treatment Of Your Patient Primary Diagnosis Code Description Secondary Diagnosis Code Description APS-STDLTD-5320 (06/20) Page 2 of 7