Critical Illness Insurance Claim Form - Metlife Form Page 7
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8Listed Conditions (check the Listed Condition(s) being claimed):
£ Addison’s disease (adrenal hypofunction)
£ Muscular dystrophy
£ Amyotrophic lateral sclerosis (Lou Gehrig’s disease)
£ Myasthenia gravis
£ Cerebral palsy
£ Necrotizing fasciitis
£ Cerebrospinal meningitis (bacterial)
£ Osteomyelitis
£ Cystic fibrosis
£ Poliomyelitis
£ Diphtheria
£ Rabies
£ Sickle cell anemia (excluding sickle cell trait)
£ Encephalitis
£ Huntington’s disease (Huntington’s chorea)
£ Systemic lupus erythematosus (SLE)
£ Legionnaire’s disease
£ Systemic sclerosis (scleroderma)
£ Malaria
£ Tetanus
£ Multiple sclerosis (definitive diagnosis)
£ Tuberculosis
Date of Illness (mm/dd/yyyy)
Date your patient first consulted
(First Symptom/Diagnosis Date)
you for this condition (mm/dd/yyyy)
Has the patient previously had the same or similar condition? £ Yes £ No If “yes,” indicate first treatment dates.
8C - Referring and Other Treating Physicians
First Name
Middle Name
Last Name
Street Address
Phone Number
City
State
ZIP Code
First Name
Middle Name
Last Name
Street Address
Phone Number
City
State
ZIP Code
For services related to hospitalization, give hospitalization dates.
Date Confined (mm/dd/yyyy)
Through (mm/dd/yyyy)
Hospital Name
Street Address
City
State
ZIP Code
Date Confined (mm/dd/yyyy)
Through (mm/dd/yyyy)
Hospital Name
Street Address
City
State
ZIP Code
CII-CLM-GENERIC-NW (05/15) Fs
Page 7 of 8
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