Claim Form - Aetna Life Insurance Company Page 2
ADVERTISEMENT
1
2PART 2: To be completed by attending physician
ATTENDING PHYSICIAN’S STATEMENT
1.
Nature of sickness or injury.
Describe any complications.
2.
If fracture or dislocation, state whether
reduced or immobilized. If fracture of
long bones, state whether fracture is
through shaft or extremity. Was it
confirmed by X-ray?
No
Yes
3.
When did symptoms first appear or
accident happen?
Date ____________________________________________
4.
When did patient first consult you for
this condition?
Date ____________________________________________
5.
Has patient ever had same or similar
condition? If yes, state when and describe.
No
Yes When? Date __________________ Describe:
6.
Describe any other disease or
infirmity affecting present condition.
7.
Nature of any surgical or obsterical
Procedure. Describe fully, include
CPT code. Where and when
performed?
Date ________________________ If in hospital, inpatient
outpatient
8.
Give dates of treatment.
9.
Is condition a result of or in any way
connected with pregnancy?
No
Yes
Inception date of pregnancy __________________________
10.
Is patient still under your care for this
condition? If discharged, indicate when.
No
Yes
When? Date __________________________
11.
If patient hospitalized, give name and
address of hospital.
____________________________________________________________________________________________
Hospital
City
State
Date admitted_________________________
Date discharged _________________________
12.
Did you file this claim with any other
Insurance Company? If yes, indicate
Name: _____________________________________________________
name and address of company.
No
Yes
Address: ___________________________________________________
PART 3: To be completed by provider
(Please Print)
NAME ____________________________________________________
SIGNED: _________________________________________________
DEGREE __________________________________
DATE ___________________________
I.D. or S.S. # ________________________________ (THIS MUST BE INCLUDED)
PHONE # ________________________________
ADDRESS: _______________________________________________________________________________________________________________________________________
Street
City
State
Zip
PATIENT’S NAME
DOES PATIENT HAVE OTHER COVERAGE?
IF YES, PLEASE IDENTIFY
YES
NO
IS CONDITION DUE TO INJURY OR SICKNESS
GIVE DETAILS:
PREGNANCY?
APPROXIMATE DATE
ARISING OUT OF PATIENT’S EMPLOYMENT?
NO
YES
YES
NO
PREGNANCY COMMENCED:
DIAGNOSIS AND CONCURRENT CONDITIONS
HASPATIENT EVER HAD SAME OR SIMLIAR CONDITION?
YES
NO
IF YES, WHEN & DESCRIBE
REPORT OF SERVICES (IF PREVIOS FORM SUBMITTED, YOU NEED ONLY DATES AND SERVICES SINCE LAST REPROT) OR ATTACH ITEMIZED BILL
DATE OF
PLACE OF
DESCRIPTION OF SURGICAL OR
SERVICES
SERVICES
MEDICAL SERVICES RENDERED
PROCEDURE CODE USED
CHARGES
______________________________________________________________
______
______________________________________________________________
______
___________________________________________________
_____
TOTAL CHARGES
$
DATE SYMPTOMS FIRST APPEARED
DATE PATIENT FIRST CONSULTED
OR ACCIDENT HAPPENED
YOU FOR THIS CONDITION
AMOUNT PAID
$_________
IS PATIENT STILL UNDER YOUR CARE FOR THIS CONDITION?
YES
NO
BALANCE DUE
$_________
NOTICE: Anyone who knowingly misrepresents or falsifies additional information requested by this
Form may upon conviction be subject to fine or imprisonment.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 48495md4 - Life And Disability Income Insurance Enrollment Form - Reliastar Life Insurance Company
Legal
Form Dd 2598-5 - Principal Life Insurance Company Principal National Life Insurance Company
Business
Form 63-20-23 - Premium Excise Return For Foreign Life Insurance Companies On Life, Accident And Health Business - 2001
Financial
Form 63-20-23 - Premium Excise Return For Foreign Life Insurance Companies On Life, Accident And Health Business - 2003
Financial
Form 63-20-23 - Premium Excise Return For Foreign Life Insurance Companies On Life, Accident And Health Business - 2004
Financial
Related Categories
Parent category: Business