Group Disability Claim Filing Instructions And Employer Initial Claim Form (Page 4 of 4) in pdf

American Fidelity Assurance Company

Mail to: AWD Benefits Department

CALIFORNIA

P.O. Box 268898

Oklahoma City, OK 73126-8898

Local Phone # (405)416-7750

Toll Free Phone # 1-800-267-2322

Local Fax# (405)523-5762

Toll Free Fax # 1-888-243-3453

PHYSICIAN - INITIAL DISABILITY CLAIM FORM

Patient’s Name:

Social Security Number:

Date of Birth:

Diagnosis:

Please list diagnosis resulting in patient’s temporary total disability (including complications)

Diagnosis: ________________________________________________________________

ICD9 Code: __________________________________

Diagnosis: ________________________________________________________________

ICD9 Code: __________________________________

Is disability the direct result of patient’s employment? Yes

❏

Is disability the result of a pregnancy? Yes

If yes, date pregnancy was diagnosed:

❏

Delivery date: (if delivered)

Expected delivery date: (if not delivered)

History:

Was the patient referred to you? Yes

Unknown

If yes, please provide name and phone number of referring physician:

❏

Date symptoms first appeared or accident happened?

Date patient first consulted you for this condition?

Are you aware if this patient has ever had the same or similar condition? Yes

If yes, please provide explanation including first date of onset.

❏

Treatment:

Is patient still under your care? Yes

If yes, date of next appointment: ________________________________________ _____

❏

List all treatment dates:______________________________________________________________________________________________________

Please describe treatment plan: _______________________________________________________________________________________________

If patient is no longer under your care, please provide name and phone number of current physician: Unknown

❏

Has patient been confined to a hospital? Yes

Admitted: ___________________________ Discharged: _____________________________

❏

Hospital Name:

Phone Number:

If surgery is/was necessary, please list procedure(s):

Date scheduled:

Date performed:

Prognosis:

California Physicians: Please answer the following question with respect to your patient's disability:

Patient was continuously totally disabled (unable to work)

1. Own occupation

Yes

No From: ___________ thru ________

2. Any occupation

Yes

No From: ___________ thru _________

❏

Total Disability from own occupation is defined as a disability that

Total Disability from any occupation is defined as: disability that renders one

renders one unable to perform with reasonable continuity the

unable to engage with reasonable continuity in another occupation in which

substantial and material acts necessary to pursue his usual

he could reasonably be expected to perform satisfactorily in light of his age,

occupation in the usual and customary ways.

education, training, experience, station in life, physical and mental capacity.

patient is currently totally disabled, please indicate the antici-

pated length of disability by checking the appropriate box below:

________________________

Months:

or Permanently Disabled ❏ or Other ❏

❏

Impairment:

List functional limitations/restrictions that render your patient temporarily totally disabled:

Attending Physician’s Name: (please print)

Degree:

Specialty:

Street Address:

City:

State/Zip Code:

Office Phone Number:

Fax Phone Number:

Federal Tax ID Number:

Form completed by:

Title:

Signature of Physician:

Date:

Attention Physician: This form documents your verification that the above named individual is totally disabled from their occupation.

You will be asked periodically for updates related to the individual’s disability and treatment plan.

BN-667(CA)-0806

Group Disability Claim Filing Instructions And Employer Initial Claim Form Page 4

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