Spousal Accident Disability Claim Form
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american Fidelity assurance Company
aCCidEnt
Mail to:
AWD Benefits Department
PO Box 268898
disaBiLty
Oklahoma City Oklahoma 73126-8898
Phone:
1-800-437-1011
Fax:
1-888-243-3453
attEnding PhysiCian’s statEMEnt
See front page for fraud warnings.
Name of Patient:
Date of Birth:
Social Security Number:
Account Number:
Diagnosis: (including complications)
ICDA Code:
d
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a
g
n
o
Is disability due to injury arising out of or in the course of patient’s employment?
o Yes
o No
s
i
s
Is disability due to an accident?
o Yes
o No
h
When did accident happen?
Date patient first consulted you for this condition?
i
______/______/______
______/______/______
s
t
Has the patient ever had the same or similar condition?
o Yes
o No
If yes, indicate when and describe:
o
r
y
Was the patient referred to you?
o Yes
o No
If yes, full name and address of referring physician:
Frequency of treatment:
o Monthly
o Weekly
o Other
Date of next appointment : _______/______/______
Nature of treatment being rendered (including surgery and any medications being prescribed)
t
r
E
List all dates of treatment or medical attention since the disability began:
a
t
M
Is patient still under your regular care for this condition?
o Yes
o No
If no, please explain and provide name of the current treating physician:
E
n
t
Has the patient been confined to a hospital?
o Yes
o No
Admitted: _____/_____/_____ Discharged: _____/_____/_____
Admitted: _____/_____/_____ Discharged: _____/_____/_____
If yes, give admit and discharge dates along with name and address of hospital.
Name:___________________________________________________ Address: ___________________________________________________
Dates of total disability: (unable to work) From: ____________________ Through: ____________________
P
Dates of partial disability?
From: ____________________ Through: ____________________
r
o
If the patient is currently disabled, what is the anticipated length of disability?
g
o 1-2 Months
o 2-3 Months
o 3-6 Months
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o
o 6-12 Months
o More than 12 Months
o Permanent
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When, in your opinion, will the patient recover sufficiently to return to work?
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s
Functional Limitations that render your patient totally disabled:
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M
P
a
Current Treatment Plan:
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M
E
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s
Attending Physician’s Name: (print)
Specialty:
Telephone #:
Fax #:
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Street Address:
City:
State:
Zip Code:
Signature:
Federal Tax ID #:
Date:
Email address:
BN-723-0510
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