Form Bn-658(Ca)-0307 - 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
Toll Free Phone # 1-800-662-1113
Toll Free Fax # 1-800-818-3453
ATTENDING PHYSICIAN’S STATEMENT
Name of Patient:
Date of Birth:
Account Number:
Diagnosis: (including complications)
ICDA Code:
D
I
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: ___________________________
S
I
Date pregnancy was diagnosed? ____/____/____ Date of delivery:(if delivered) ____/____/____ Expected date of delivery? ____/____/____
S
When did symptoms first appear or accident happen?
Date patient first consulted you for this condition?
H
______/______/______
______/______/______
I
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)
T
r
E
List all dates of treatment or medical attention since the disability began:
A
T
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:
E
N
T
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: ___________________________________________________
California Physicians: Please answer the following question with respect to your patient’s disability:
Patient was continuously totally disabled (unable to work)
1. Own occupational o Yes o No From: __________ thru __________
2. Any occupation o Yes o No From: __________ thru __________
Total disability from own occupation is defined as a disability that renders one
Total disability from any occupation is defined as: disability that renders one
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unable to perform with reasonable continuity the substantial and material acts
unable to engage with reasonable continuity in another occupation in which
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necessary to pursue his usual occupation in the usual and customary ways.
he could reasonably be expected to perform satisfactorily in light of his age,
o
education, training, experience, station in life, physical and mental capacity.
G
N
Dates of partial disability?
From: ____________________ Through: ____________________
o
S
I
If the patient is currently disabled, what is the anticipated length of disability?
S
o 1-2 Months
o 2-3 Months
o 3-6 Months
o 6-12 Months
o More than 12 Months
o Permanent
When, in your opinion will the patient recover sufficiently to return to work?
Functional Limitations that render your patient totally disabled:
I
M
P
A
Current Treatment Plan:
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M
E
N
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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)
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)
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Street Address:
City:
State:
Zip Code:
Signature:
Federal Tax ID #:
Date:
Are you a member of Kaiser Permanente or Kaiser Foundation?
E-mail Address:
o Yes o No
BN-658(CA)-0307
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