Form Bn-451-Afes - Individual Cancer, Intensive Care Or Dread Disease Benefit Statement Page 2
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2ATTENDING PHYSICIAN’S STATEMENT
Warning: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim
containing any false, incomplete, or misleading information may be guilty of insurance fraud and subject to criminal and
civil penalties.
1. Patient’s Name______________________________________________________________Age ________ Date of Birth___________
2. Diagnosis _____________________________________________________________________________
(ICDA Code)_________
3. When did symptoms first appear? ___________________________________________________ Date_________________________
4. When did patient first consult you for this condition? _____________________________________ Date_________________________
5. Has patient ever had same or similar condition?
Yes
No (If “Yes” state when and describe)
____________________________________________________________________________________________________________
6. Was patient referred to you by another physician?
Yes
No If yes, list name and address of referring physician
Name __________________________________________________________ Address_____________________________________
7. If patient hospitalized, give name and address of hospital. _____________________________________________________________
Admit Date______________________ Discharge Date_______________________
Date____________________________ Signed_____________________________________________________________________
Degree
(Street Address)
(City or Town)
(State)
(Zip Code)
Tax ID Number_______________________________
BN-451-AFES (1007)
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Parent category: Business