Medically Necessary Leave Of Absence Verification Form
ADVERTISEMENT
1Medically Necessary Leave of Absence
Verification Form
Please forward the completed form to Coventry Health Care of Georgia, Inc., Eligibility Department, PO Box 61017, Harrisburg, PA 17106-1017
PART I
SUBSCRIBER’S NAME (Print Last, First, Middle Initial)
SUBSCRIBER’S ID NUMBER
EMPLOYER NAME & COVENTRY GROUP NUMBER
ADDRESS (Street, City, State, and ZIP Code)
TELEPHONE NUMBER
Full Name Of Dependent
Dependent’s Date of Birth
Dependent’s Sex
o
Female
o Male
Is Dependent currently enrolled as a full-time student in a post-secondary educational institution?
o Yes
o No If “YES”, provide name and address of post-secondary educational institution and dates of attendance.
Institution
Institution’s Address
Dates of Attendance
Date Illness Occurred
Does the Dependent qualify as “disabled” under Medicare, Medicaid, Social Security Administration, Veterans Administration, or other government
agency?
Yes
No
If Yes, please attach a copy of the disability certification
o
o
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE.
Subscriber’s Signature
Date Signed
PART II (To be completed by an attending physician)
Is the Dependent incapable of self-support because of illness?
o Yes
o No
PRIMARY DIAGNOSIS:______________________________________________________________________________________________________
SECONDARY DIAGNOSIS:______________________________________________________________________________________________________
How does the illness interfere with pursuing or continuing an education?
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
How long do you anticipate such illness may continue?
o Permanently o Temporarily If Temporarily: o 6 Months
o 1 Year
o 2 Years
o Other:_________________________
Assessment based upon (check one or more):
o Physical Exam
o Review of Medical Records
o Appropriate Tests and Diagnostic Procedures
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE.
Attending Physician’s Signature
Date Signed
Attending Physician’s Name (Printed)
Daytime Telephone Number
For Internal Coventry Use Only
o Approve
o Deny
Comments: ___________________________________
Medical Director’s Signature
Date Signed
_____________________________________________
Medical Director’s Name (Printed)
Medical Leave of Absence Verification Form-1109
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business