Form Abj10368g-3 - Group Voluntary Std / Ltd / Waiver Of Premium Claim - 2013 Page 4
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6ATTENDING PHYSICIAN’S STATEMENT (PHYSICIAN)
Patient’s Name:
Age:
1.
Diagnosis:
2.
If condition is due to pregnancy, what is expected delivery date? Date
/
/
MO/DAY/YR
3.
When did symptoms first appear or accident happen?
Date
/
/
MO/DAY/YR
4.
When did patient first consult you for this condition? Date
/
/
MO/DAY/YR
5.
Has patient ever had same or similar condition? (If “yes,” state when and describe.)
Yes
No
6.
Describe any other diseases or infirmity affecting present condition.
7.
Nature of surgical or obstetrical procedure, if any (describe fully).
8.
Is patient unable to perform job duties?
Yes
No
If yes, from
through
9a. What specific job duties is patient unable to perform?
9b. Specific RESTRICTIONS (What the patient should not do and why). Please quantify in hours, weight, etc.
9c. Specific LIMITATIONS (What the patient cannot do and why).
10. If retired or unemployed which activities of daily living (ADLs) is patient unable to perform?
11. Date patient last examined by you:
Frequency of visits:
weekly
monthly
other
12. Is patient:
ambulatory
bed confined
house confined
other
13. If patient is hospitalized, give name and address of hospital.
Hospital:
City:
State:
14a. Date admitted:
/
/
Date discharged:
/
/
MO/DAY/YR
MO/DAY/YR
14b. When do you expect patient to resume partial duties?
/
/
Full duties?
/
/
MO/DAY/YR
MO/DAY/YR
14c. If patient is unemployed or retired, on what date would you expect a person of like age, gender and good health to resume his/her normal and
necessary activities?
/
/
MO/DAY/YR
15. Is condition due to injury or sickness arising out of patient’s employment?
Yes
No
If “yes,” explain.
16. Referring Physician:
Phone: (
)
Mailing Address:
PHYSICIAN VERIFICATION
Signed:
, MD
Date:
/
/
Phone: (
)
MO/DAY/YR
Street Address:
City/Town:
State/Province:
Zip Code:
ABJ10368G-3
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