Claim For Continuing Credit Disability Benefits Form (Page 2 of 2) in pdf

SECTION C - STATEMENT OF ATTENDING PHYSICIAN (Please Print)

If this claim form is not fully completed, processing of benefits will be delayed until all required information has been received. Write N/A in non-applicable sections.

Patient Name (Please Print)

Height

Weight

Date of Birth

Social Security Number

I I I I

I I I I I I I I I I I I I I

I I I I

I I I I I I I I

–

A. When did symptoms first appear

B. Date of 1st consultation

C. Date you advised your patient

D. Has patient ever had same

If Yes, when?

or accident happen?

for this condition

to stop working

or similar condition?

______/______/______

Yes

______/______/______

E. Is condition due to or exacerbated by an injury or sickness arising

F. Name and address of referring physician (If any)

out of patient’s employment?

Yes

Unknown

A. Diagnosis (Including any Complications) Include ICD 9 code

B. Subjective symptoms

D. Describe other conditions and/or factors that are contributing

C. If condition is due to an injury, is it:

New

Yes

to patient’s illness or injury

Recurring

Yes

A. Date of last visit

B. Date of next visit

C. Frequency of visits

______/______/______

D. Describe current and future treatment plan (including surgery and medications prescribed, if any.) Provide all applicable dates.

A. Has patient

B. Is patient

Recovered

Improved

Unchanged

Retrogressed

Ambulatory

Bed Confined

House Confined

Hospital Confined

C. If unchanged or retrogressed, please explain:

D. When will patient:

Return to Patient’s Occupation

1–3 mos.

3–6 mos.

6–12 mos.

more than 12

Never

Return to Any Occupation

1–3 mos.

3–6 mos.

6–12 mos.

more than 12

Never

E. Has patient been admitted to a hospital?

F. Name and address of hospital

Yes

If Yes, confined from

______/______/______to______/______/______

Cardiac (if Applicable)

A. Functional Capacity

B. Therapeutic Class (Activity)

C. Blood pressure last visit

(American Heart Assn.)

Class 1 (no limitation)

Class 3 (marked limitation)

A. (no restric.)

C. (moderate restric.)

Class 2 (slight limitation)

Class 4 (complete limitation)

B. (slight restric.)

D. (marked restric.)

_________________________________

E. (complete restric.)

Systolic/Diastolic

Physical Impairment (*As defined in federal dictionary of occupational titles)

Remarks:

Class 1 - No limitation of functional capacity; capable of heavy work.* No restrictions. (0–10%)

Class 2 - Medium manual activity.* (15–30%)

Class 3 - Slight limitation of functional capacity; capable of light work.* (35–55%)

Class 4 - Moderate limitation of functional capacity; capable of clerical/administrative (sedentary*) activity. (60–70%)

Class 5 - Severe limitation of functional capacity; incapable of minimum (sedentary*) activity. (75–100%)

A. Does patient currently have

B. Describe specific limitations and/or restrictions

Limitations/restrictions from:

Patient’s Occupation:

Yes

Any Occupation:

Yes

C. If the limitations and/or restrictions can be accommodated, would you release patient to return to work?

Yes

D. Date employment could begin

If Yes:

Part time

Full time

If No, explain:

______/______/______

Are you, the physician, related to this

patient?

Yes

If Yes, what is the relationship?

Name of Attending Physician - PLEASE PRINT

Degree & Specially

Telephone Number

I I I I I I

I I I I I I I I

Street Address

City

State

Zip

–

Fax Number

______/______/______

I I I I I I

I I I I I I I I

–

Signature of Attending Physician (The above statement are true and complete to the best of my knowledge.)

Date

(Stamped signature is not acceptable.)

CCF (4/06)

Claim For Continuing Credit Disability Benefits Form Page 2

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