Hospitalization Insurance Claim - Insured'S Sured'S Statement Statement Page 2
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2ATTENDING PHYSICIAN’S STATEMENT (
–
.
TO BE FILLED OUT AND RETURNED TO THE PATIENT
THE PATIENT IS RESPONSIBLE FOR ANY RELATED CHARGES
Patient’s first and last name
Are you related to the patient?
If so, specify relationship.
Yes
No
1. DIAGNOSTIC
Current diagnosis
Specify any other condition or complication
The patient’s condition is attributable to
Specify
an accident
an illness
2. HISTORY OF THIS MEDICAL CONDITION
Has the patient remained under your care since the onset of the illness or accident?
Yes
No
Date on which the patient was referred to you
If the patient was referred to you by other physicians, indicate their names and
addresses
⎯⏐⎯ m ⎯⏐⎯ ⎯
D
Y
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According to the medical record, indicate the date of
Name of attending physician at that date
the first symptoms of the illness or accident
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⏐⎯
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Y
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For the illness or accident in question, indicate the date
Date of your last consultation
of your first consultation
⎯⏐⎯ m ⎯⏐⎯ ⎯
⎯⏐⎯ m ⎯⏐⎯ ⎯
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D
Y
⎯ ⎯⏐
⏐⎯
D
Y
⎯ ⎯⏐
To your knowledge, was this patient treated or did the patient take medication in relation to the cause of the hospitalization in
the 12 months prior to the effective date of the insurance (indicated in the upper right-hand corner on the reverse)? If so,
indicate the name of the attending physician
Yes
No
Physician’s name : ______________________________________________________________________________________________
Dates : _______________________________________________________________________________________________________
3. HOSPITALIZATION
Reason for hospitalization
Describe the surgery, if any
Name of facility
City
Date of admission
Date of release
Stay in intensive care
⎯⏐⎯ m ⎯⏐⎯ ⎯
Time :
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⎯⏐Time :
necessary
not necessary
D
Y
D
Y
⏐⎯
⎯ ⎯⏐
⏐⎯
⎯
⎯⏐⎯ m ⎯⏐⎯ ⎯
⎯⏐⎯ m ⎯⏐⎯ ⎯
Date of admission in intensive care
Date of release in intensive care
⏐⎯
D
Y
⎯
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D
Y
⎯
⎯⏐
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Date of first consultation
Indicate whether hospitalization was due to
an acute illness
a chronic illness
⎯⏐⎯ m ⎯⏐⎯ ⎯
convalescence
other
⏐⎯
D
Y
⎯ ⎯⏐
Was the patient hospitalized before in
If so, indicate the date of hospitalization
If the patient is still hospitalized,
relation to this illness or a related illness?
provide the approximate date of his/her
Yes
No
⎯⏐⎯ m ⎯⏐⎯
hospitalized?
⎯⏐⎯ m ⎯⏐⎯
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D
Y
⎯⏐
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D
Y
⎯⏐
4. CONVALESCENCE
If the hospitalization exceeds 15 days, do you consider the patient subsequently totally disabled to warrant a convalescence
period? For a person without Remunerative Work, totally disabled means the state of disability that prevents the Primary Insured
from attending to most of his or her normal activities of daily living.
Yes
No If so, period of convalescence : From _________________________ To _______________________________.
5. ATTENDING PHYSICIAN
Physician’s name (in block letters)
Licence Number
Address
City
Telephone Number
Signature
Date
⎯⏐⎯ m ⎯⏐⎯
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Y
⏐⎯
⎯⏐
2012/01/24
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