Form Bn-658-1007 - Group Disability Claim Page 4
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4American Fidelity Assurance Company
Mail to:
AFES Benefits Department
P.O. Box 25160
Oklahoma City, OK 73125-0160
Local Phone # (405) 523-5025
toll Free Phone # 1-800-662-1113
toll Free Fax # 1-800-818-3453
AttEnding PhysiCiAn’s stAtEMEnt
Warning: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a statement of claim containing any false, incomplete, or misleading
information may be guilty of insurance fraud and subject to criminal and civil penalties.
Name of Patient:
Date of Birth:
Account Number:
Diagnosis: (including complications)
ICDA Code:
d
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A
Is disability due to injury or sickness arising out of or in the course of patient’s employment?
o Yes
o No
g
n
o
Is disability the result of pregnancy? o Yes
o No
If yes, type of delivery: ___________________________
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i
Date pregnancy was diagnosed? ____/____/____ Date of delivery:(if delivered) ____/____/____ Expected date of delivery? ____/____/____
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When did symptoms first appear or accident happen?
Date patient first consulted you for this condition?
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______/______/______
______/______/______
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s
Has the patient ever had the same or similar condition?
o Yes
o No
If yes, indicate when and describe:
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o
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Was the patient referred to you?
o Yes
o No
If yes, full name and address of referring physician:
y
Frequency of treatment:
o Monthly
o Weekly
o Other
Date of next appointment : _______/______/______
Nature of treatment being rendered (including surgery and any medications being prescribed)
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r
E
List all dates of treatment or medical attention since the disability began:
A
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M
Is patient still under your regular care for this condition?
o Yes
o No
If no, please explain and provide name of the current treating physician:
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Admitted: _____/_____/_____ Discharged: _____/_____/_____
Has the patient been confined to a hospital?
o Yes
o No
Admitted: _____/_____/_____ Discharged: _____/_____/_____
If yes, give admit and discharge dates along with name and address of hospital.
Name:___________________________________________________ Address: ___________________________________________________
Dates of total disability: (unable to work) From: ____________________ Through: ____________________
Disabled from: Patient’s Job
o Yes
o No
Any other work
o Yes
o No
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Dates of partial disability?
From: ____________________ Through: ____________________
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If the patient is currently disabled, what is the anticipated length of disability?
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o 1-2 Months
o 2-3 Months
o 3-6 Months
o
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o 6-12 Months
o More than 12 Months
o Permanent
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When, in your opinion, will the patient recover sufficiently to return to work?
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Functional Limitations that render your patient totally disabled:
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M
P
A
Current Treatment Plan:
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E
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Attention Physician: This form documents your verification that the above named individual is totally disabled from either their occupation or any other occupation.
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Your signature generates disbursement of disability benefits. You will be asked periodically for updates related to this individual’s disability status and treatment plan.
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Attending Physician’s Name: (print)
Specialty:
Telephone #:
Fax #:
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Street Address:
City:
State:
Zip Code:
Signature:
Federal Tax ID #:
Date:
Email address:
BN-658-1007
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