Claim Form Hippa - 10-830 Page 2
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1
2
3PART II LOAN INFORMATION
Disability Certificate Number
_
Effective Date
Payment Date
_
Dealership Name
_
Dealership Phone (
VIN. #
_
New Car CI Used Car CI Year
Make
_
Model
_
CREDITOR'S NAME AND ADDRESS
(The CREDITOR is the entity to which you make your payments)
BankiAnance Company Name
_
Address
_
City
State __
Zip
_
Phone (
Monthly Payment
Loan Number
_
Has Loan been renewed, refinanced or paid off?
DYes
D No
If Yes, please
provide
corresponding
paperwork.
PART'"
A MUST BE COMPLETED BY EMPLOYER OR SELF IF SELF-EMPLOYED
(altered answers are not acceptable)
Employee's Name
If Industrial, please describe how Injury or Illness occurred
Date Employee first became unable to work due to disability
________
:20___
Carrier's Address
_
Date returned to work ....,.._-,--,----,....,..-,-_-,..
20
_
Reason for Employee's loss of time (check one)
CI Personal Injury
0 Laid Off
o
Personal Illness
0 Discharged
CI Industrial Injury/Illness
0 Other (Explain)
Date Hired
_
Occupation
_
Usual number of hours worked per week
_
D~ies
_
Employer's Name
_
Employer's Address
_
_
Phone(
Name of Worikman's Compensation Carrier
Preparer's Signature
_
Title
Date
20
PART III B INSURED'S STATEMENT IF NOT EMPLOYED (Altered answers are not acceptable)
Have you ever received unemployment benefits?
0 Yes
0 No
II Yes, please provide copies of any &. all unemployment
Benefits 0 Are being paid currently
records Including detailed printout(s) of all payment received.
D Were paid from
to
Patient's Name
_
PART IV PHYSICIAN'S STATEMENT (Physician's
Nole: Please print or type) (Altered answers are not acceptable)
Normal Pregnancy: CI Yes 0 No, Complications are
Date of Birth ___j __ /__
Height
Weight
_
If she were not pregnant, would she be disabled from any other condition?
Is condition due to pregnancy?
0 Yes
CI No
Beginning Date of Pregnancy
20___
0 Yes, State condition
0 No
SPECIFIC DISABLING CONDITION
Has patient ever had same or similar condition? 0 Yes D No
When did symptoms appear or accident happen?
-"0
Date patient ceased work due to this disability
20
Other conditions patient has been treated for in the past 4 years:
II yes, when
______
,20
Name and address of physician previously treating for same or
similar condition
_
Name and addresses of regular physician or other physician
Has patient been hospitalized for this condition? 0 Yes 0 No
mEATMENT
Date patient first consulted you for this condition
20
Frequency of visits:
0 Weekly
0 Monthly
0 Other, List:
When did you last examine the patient for this condition?
20__
When is patient's next scheduled appointment?
20
"yes, dates of hospitalization
20 __
to
20 __
Hospital Name
_
Address
=-;-__ --:::;--
_
City
State __
Zip
Signature of physician
_
PROGNOSIS
Is patient now totally disabled from their:
REGULAR OCCUPATION?
ANY OCCUPATION?
Date total disability began
Date you released Patient to return to work
DYes
ONo
DYes
ONo
_____
.20
_____
20
If patient has not been released, when in your opinion, may patient
return to worik
20
Date
,20 __
Specialty
_
TYpe/Print Physician's Name
_
Degree
Phone (
Address
___
Clty
State __
Zlp
_
Complications
slowing reccverv
_
FaxNumber
___
ANY RESTRICTIONS?
_
THE INSURED IS RESPONSIBLE FOR ANY AND ALL CHARGES INCURRED FOR THE COMPLETION
ON THIS FORM
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