Physician Statement Form (Page 2 of 2) in pdf

Patient’s Diagnosis:

Did you perform an actual examination?

Yes

Date of the exam: ____ / _____ / _________

Please indicate the primary diagnosis for which you examined the patient:

__________________________________________________________________________________________________

ICD-9 Code: _______________

Date symptoms first appeared or accident occurred: ____ / _____ / _________

Is this condition a complication of an underlying condition?

Yes (specify below)

__________________________________________________________________________________________________

Please list the dates of the patient’s office visits in the 120 days before the insurance purchase date, noted above. Circle

the dates where you treated the patient for the above stated condition.

____ / _____ / ___________

Did you advise the trip be cancelled or interrupted due to the patient’s medical condition?

Yes Date: ___ / ___ / _________

Please explain why you made this recommendation.

Please explain why you did not make this recommendation.

Provide details on the circumstances and medical diagnosis

of the patient that you consider relevant to the insured’s

decision to cancel or interrupt their trip due to injury or

illness.

________________________________________________

If the patient is the insured, on what date did he/she become medically unable to travel?

___ / ___ / ________

By my signature and stamp below, I hereby certify that the above is true and correct

Physician Signature: _________________________________________________ Date ____/____/______

Physician Stamp:

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 Page 2