Physician Statement Form printable pdf download

Physician Statement Form

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*Physician Statement*

Physician Statement Form

To be completed by Primary Insured

Primary Insured’s Name:

Policy Number:

Insurance Purchase Date:

To be completed by Examining Physician

Patient Information

Patient’s Name: ___________________________________

Date of Birth: _____ / ________ / _____________

Street Address: ___________________________________

City: ______________

State: ____

Zip Code: _______

Physician Information

Examining Physician’s Name: ________________________

Specialty: _______________________________________

Street Address: ___________________________________

City: ______________

State: ____

Zip Code: _______

Phone: (______) ______ -- ____________

Fax:

(______) ______ -- ____________

Are you the patient’s primary care physician?

Who is this patient’s primary care physician?

Name: __________________________________________

Yes

Phone: (_____) _______ -- ___________

Was the patient referred to you by the primary care

physician?

Yes

E-mail to:

Mail to: Allianz Global Assistance, P.O. Box 72031, RICHMOND, VA 23255-2031

Call: 1-800-334-7525 Fax to: 804-673-1469. We are available 24 hours a day.

Insurance underwritten by BCS Insurance Company or Jefferson Insurance Company or Nationwide Life Insurance Company

or National Casualty Company or Allied Property Casualty Insurance Company or Nationwide Mutual Insurance Company

Please refer to your policy or letter of confirmation to determine your underwriter

Plan administered by AGA Service Company

Physician Statement Form