Form Bn-688-1007 - Routine Pregnancy - 2007 Page 2
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1
2American 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
SECTION 3: 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:
Diagnosis:
ICDA Code:
D
I
A
T ype of delivery: ________________________________________________ _ ________________________________________________________________
G
N
O
S
Date pregnancy was diagnosed? ____/____/____
I
S
Date of delivery: (if delivered)
___/____/_____
____/____/____
When did symptoms first appear?
H
____/____/____
Date patient first consulted you for this condition?
I
S
❒ Yes
❒ No
Was the patient referred to you?
If yes, full name and address of referring physician: ________________________________________
T
O
_____________________________________________________________________________________________________________________________
R
Y
_____________________________________________________________________________________________________________________________
Has the patient been confined to a hospital?
❒ Yes
❒ No
T
R
Admitted: _____/_____/_____ Discharged: _____/_____/_____
E
A
If yes, give admit and discharge dates along with name and address of hospital.
T
M
Name: _______________________________________________________________________________________________________________________
E
N
Address:______________________________________________________________________________________________________________________
T
P
R
O
G
N
Dates of total disability: (unable to work) From: ______________________________________ Through: ________________________________________
O
S
I
S
Attending Physician’s Name: (print)
Degree:
Telephone #:
Fax #:
(
)
-
(
)
-
Street Address:
City:
State:
Zip Code:
Signature:
Federal Tax ID #:
Date:
BN-688-1007
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