Initial Statement Of Claim Disability Benefit Page 3
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3PART III
ATTENDING PHYSICIAN'S STATEMENT (PLEASE ANSWER ALL QUESTIONS AND SIGN)
Patients Name
Social Security Number
Diagnosis and Concurrent Conditions (including ICD-9 codes)
Surgical or Obstetrical Procedure
Current Medications
Frequency of Treatment
Weekly
Other
Monthly
Has patient ever had same
If Yes, when
Is condition due to injury
Yes
or sickness arising from
No
or similar symptoms?
Yes
patient's employment?
No
Date symptoms first appeared or accident happened
Date patient first consulted you for this condition
Is patient still under
your care for this
Yes
condition?
No
If condition is due to pregnancy,
If patient hospitalized,
give LMP and expected date
LMP ________________
give name of hospital
Admission Date __________________
of delivery.
Expected Date of delivery ________________
Discharge Date __________________
Is patient able to perform his/her job?
Yes
Date patient was continuously
No
unable to work
From _______________
To
_______________
Estimate date patient should be able to return to work.
Patient will be partially disabled
From:
To:
MENTAL CONDITION
Is the patient competent to endorse checks and direct the use of the proceeds thereof?
Yes
No
COMPLETE THIS SECTION ONLY IF DISABILITY IS DUE TO CARDIAC CONDITION
CARDIAC
Functional Capacity (American Heart Ass'n)
Class 1 (no limitation)
Class 2 (slight limitation)
Class 3 (marked limitation)
Class 4 (complete limitation)
Blood Pressure and Dates
COMPLETE THIS SECTION ONLY IF DISABILITY IS DUE TO VISUAL IMPAIRMENT
VISUAL IMPAIRMENT
Snellen Notation
Month
Day
What was vision at
With Glasses
O.D.
O.S.
20
last observation?
Month
Day
Without Glasses
O.D.
O.S.
20
Any person who knowingly and with intent to injure Reliance Standard Life Insurance Company files a statement of claim or
submits any information in conjunction with a claim containing fraudulent, false, misleading, incomplete or deceptive information
commits a fraudulent insurance act, which is a crime. These actions will result in the denial of the claim, and are subject to
prosecution under state and/or federal law. Reliance Standard Life Insurance Company will pursue any and all appropriate legal
remedies arising from such fraudulent insurance acts.
Physician's Name, Address, ZIP (Please Print or Type)
Telephone Number
Fax Number
Specialty
(
)
(
)
Physician's Signature
Date
Degree
Physician’s Tax ID No.
IMPORTANT: PLEASE ATTACH ALL MEDICAL RECORDS FROM THREE (3) MONTHS PRIOR TO DATE OF DISABILITY TO PRESENT.
EF-1029
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