Spousal Disability Rider Claim Form Page 4
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4ATTN: AWD BENEFITS DEPT.
P.O. Box 268898
REQUEST FOR SPOUSAL
Oklahoma City, Oklahoma 73126
DISABILITY RIDER BENEFITS
Toll Free: 1-800-437-1011
Fax: 1-888-243-3453
SECTION 3 - ATTENDING PHYSICIAN’S STATEMENT
Name of Patient:
Date of Birth:
Account Number:
Social Security Number:
Diagnosis: (including complications)
ICDA Code:
When did accident happen?
Date patient first consulted you for this accident?
_______/______/______
_______/______/______
Has the patient ever had the same or similar condition?
r Yes
r No
If yes, indicate when and describe.
Was the patient referred to you?
r Yes
r No
If yes, full name and address of referring physician:
Frequency of treatment:
r Monthly
r Weekly
r Other
If not under your regular care and attendance please explain.
Date of next appointment : _______/______/______
Nature of treatment being rendered (including surgery and any medications being prescribed) and the current treatment plan:
List all dates of treatment or medical attention since the disability began:
When, in your opinion, will the patient recover sufficiently to return to his or her Daily Living Activities?
r 1-2 Months
r 2-3 Months
r 3-6 Months
r 6-12 Months
r More than 12 Months
r Permanent
Attending Physician’s Name:(print)
Specialty:
(
)
-
(
)
-
Telephone #:
Fax #:
Street Address:
City:
State:
Zip Code:
Signature:
Federal Tax ID #:
Date:
BN-717(AWD)-0712
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