Form Bn-688(Ca)-0212 - Routine Pregnancy Claim - 2012 Page 3
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3ATTN: AFES BENEFITS DEPT.
P.O. Box 25160
REQUEST FOR ROUTINE
Oklahoma City, Oklahoma 73125
PREGNANCY BENEFITS
Toll Free: 1-800-662-1113
Fax: 1-800-818-3453
SECTION 3: ATTENDING PHYSICIAN’S STATEMENT
Name of Patient:
Date of Birth:
Social Security Number:
Diagnosis:
ICDA Code:
D
I
T ype of delivery: ________________________________________________ _ ________________________________________________________________
A
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
Was the patient referred to you?
Yes
No
If yes, full name and address of referring physician: _________________________________________
r
r
T
O
____________________________________________________________________________________________________________________________
R
Y
_____________________________________________________________________________________________________________________________
Has the patient been confined to a hospital?
Yes
No
r
r
T
R
E
Admitted: _____/_____/_____ Discharged: _____/_____/_____
A
T
If yes, give admit and discharge dates along with name and address of hospital.
M
Name: _______________________________________________________________________________________________________________________
E
N
Address:______________________________________________________________________________________________________________________
T
P
R
O
G
N
O
Dates of total disability: (unable to work) From: ______________________________________ Through: ________________________________________
S
I
S
Attending Physician’s Name: (print)
Degree:
Telephone #:
Fax #:
(
)
-
(
)
-
Street Address:
City:
State:
Zip Code:
Signature:
Federal Tax ID #:
Date:
BN-688(CA)-0212
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