Disability Claim Form - Principal Financial Group Page 3
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7Attending Physician’s Statement
This completed form may be faxed to Principal Life at 1-800-255-6609.
To Be Completed By Physician – Please include office notes and test results from date of disability to present.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or
requiring genetic information of employees or their family members. In order to comply with this law, we are asking that you not provide any genetic
information when responding to this request for medical information.
Patient’s name
Date of birth
Social Security No.
Height
Weight
Blood Pressure (last visit)
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Patient is/was unable to work due to :
Injury
Illness
Pregnancy
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Diagnosis:
ICD-9 Diagnosis Code(s):
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List any complications your patient is experiencing:
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Objective Findings (X-rays, EKG’s, MRI results, lab data and clinical findings)
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Subjective Symptoms
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When did symptoms first appear or accident happen?
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Is this condition due to injury or illness arising out of patient’s employment?
yes
no
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Did this condition already exist and become exacerbated by employment?
yes
no
Please explain:
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Is patient competent to endorse checks and direct the use of those proceeds?
yes
no
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Date of first visit
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Date of last visit
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Date of next visit
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Frequency of visits
Has your patient been hospitalized?
yes
no
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From:
To:
Hospital name/number:
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If yes, when
Has your patient ever had the same or similar condition?
yes
no
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NATURE OF TREATMENT – Please specify all surgeries, medications AND dosage, therapy, and/or referrals.
Date of surgery
Type of surgery
CPT-4 Codes
If the patient was referred to you or by you to another physician list the Physician’s name, address and phone number of the Physician:
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PREGNANCY CLAIMS ONLY
What is the expected date of delivery?
Date First Treated
Date Last Treated
Date of Delivery
Bed confined?
yes
no
If yes, date began
If patient has delivered, type of delivery
Vaginal
C-Section
From:
To:
If complications are present prior to delivery, what complications is your patient experiencing?
GP60515-01
Page 3 of 7
05/2013
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