Physician Statement Stroke Claim Form (Page 2 of 3) in pdf

5. Contact information for Primary Care Physician:

Physician name ____________________________________________________ Phone Number ( _______ ) - _____________________________

Address __________________________________________________ City ______________________________ State ______ Zip code ________

Please list any other physicians consulted or hospitals attended by your patient for this or any other related disorder:

Physician name ____________________________________________________ Phone Number ( _______ ) - _____________________________

Address __________________________________________________ City ______________________________ State ______ Zip code ________

Physician name ____________________________________________________ Phone Number ( _______ ) - _____________________________

Address __________________________________________________ City ______________________________ State ______ Zip code ________

Name of Hospital ___________________________________________________ Phone Number ( _______ ) - _____________________________

Address __________________________________________________ City ______________________________ State ______ Zip code ________

Hospitalization dates:

From _____ / ______ / ________ to _______ / _______ / _______

Name of Rehabilitation Facility ________________________________________ Phone Number ( _______ ) - _____________________________

Address __________________________________________________ City ______________________________ State ______ Zip code ________

Hospitalization dates:

From _____ / ______ / ________ to _______ / _______ / _______

6. Please provide details of your patient’s tobacco use including amount per day and date last used: ____________________________________

________________________________________________________________________________________________________________________

7. Please provide any other information that would be helpful in the assessment of your patient’s claim: ________________________________

________________________________________________________________________________________________________________________

Signature of Physician _____________________________________________ Date _______________ Phone ______________________________

Printed Name of Physician _________________________________________ Address ________________________________________________

________________________________________________

PS-Stroke 09-15 Page 2 of 3

Physician Statement Stroke Claim Form Page 2