Form Di-1-Pp - Application For Disability Benefits Covered By Act 139 (Page 4 of 4) in pdf

MEDICAL OR PSYCHOLOGICAL CERTIFICATE

PART C

2. Medical record number:

1. Patient’s name:

4. Diagnosis (Medical data that, to your knowledge, disables the

3. Disability related to:

YES

patient).

USE MEDICAL DIAGNOSTIC CODE).

Specify the

complications, if the incapacity is by pregnancy.

The Job

An automobile accident

5. Treatment period (month-day-year)

From_______________________ To ______________________

6. Disability period (month-day-year)

From_______________________To________________________

7. In case of pregnancy or abortion it indicates

9. Date of the dismemberment or the loss of total and permanent

(month-day-year)

sight

(month-day-year)

Probably delivery date:___________________________________

10. If the dismemberment or the loss of the total and permanent

sight, and if is due to an accident, indicate the date

Delivery date:___________________ Abortion date:____________

(month-day-year)

11. The loss sight is total and permanent?

8. The patient one was hospitalized by 24 hours or more:

YES

From___________________

To_______________________

(month-day-year)

C E R T I F I C A T I O N

I certify that the above information is correct, and that I am a physician, psychologist or chiropractor authorized to practice my profession,

or medical guard of record. I know that the Act 139 of 1968, in Section 11 (a), provides severe penalties-such as fine, jail or both pains, to

discretion of Court-by offering deception relative to a disability benefits claims.

Physician’s Signature:

Date (month-day-year):

Physician’s Name (Print):

License number:

Local Address:

Phone:

Fax:

E-mail:

BY INCAPACITY

The Disability Benefits Act provides the payment of benefits by diseases or injuries that are not related to the work or to

automobile accidents. The payments can fluctuate between $12 and $113 weekly, and extend up to 26 weeks. The

disabled worker must file for these benefits during the three (3) following months at the beginning of the incapacity. If he

(she) files later, indicate the reason of the delay.

BY DISMEMBERMENT

Dismemberment or total losses and permanent of the sight as a result of some compensable incapacity by this Act, the

affected worker could receive between $2,000 and $4,000 of compensation. He (she) must claim these benefits not later

than six (6) months since dismemberment or the loss of the sight occurred.

BY DEATH (FOR DEPENDENTS)

A death benefit of $4,000 prorated between the direct dependents of an assured worker deceased due to a compensable

condition by this Act, if the death happens in the beginning in the following year of the incapacity. The dependents could

also receive the benefits owed to the worker. They should file for these benefits not later than six (6) months after the

worker’s death.

Form Di-1-Pp - Application For Disability Benefits Covered By Act 139 Page 4

Related Articles

Related forms

Related Categories