Fillable Bcbs Attending Physician Statement General printable pdf download

ATTENDING PHYSICIAN STATEMENT

Clear Form

GENERAL

PO Box 4030 Saskatoon SK S7K 3T2

306.244.1192 Toll-free in Saskatchewan 1.800.667.6853

Fax 306.652.5751

Instructions

1. Please print.

3. Part II–VI to be completed by physician.

2. Part I to be completed by

patient.

4. Any fee for completing this form is the patient’s responsibility.

PART I: PATIENT AUTHORIZATION

Name ___________________________________________________________ Date of Birth _________I_________ I________

Last

First

Initial

YYYY

I hereby authorize the release of any information herein requested by my insurer or its agent.

Signature _________________________________________________________ Date __________________________________

PART II: ATTENDING PHYSICIAN

Name ________________________________________________________________ Specialty __________________________

Address _________________________________________________________________________________________________

Telephone __________________________ Fax __________________________ Email _________________________________

Part III: HISTORY OF PRESENT CONDITION(S)

1. If condition is related to pregnancy, indicate date or expected date of delivery (attach prenatal clinical notes) ____ I_

_ I ___

YYYY

2. Is condition due to injury or sickness arising from the patient’s employment?

Yes

Unknown

Have workers compensation forms been completed?

Yes

Unknown

3. a. Primary diagnosis ___________________________________________

Scale: DSM (_____) Grade (_____)

__________________________________________________________

Class (_____) Grade (_____)

b. Secondary diagnosis _________________________________________

Scale: DSM (_____) Grade (_____)

__________________________________________________________

Class (_____) Grade (_____)

c. Date symptoms first appeared or accident happened ____ I_

_ I

YYYY

d. Initial examination date

____ I_

_ I

YYYY

e. Date patient ceased working due to this condition

____ I_

_ I

YYYY

f. Symptoms (include severity & frequency)

______________________________________________________________________________________________

_________________________________________________________________________________________________

g. Clinical findings (attach copies of X-rays, test results, etc.)

_________________________________________________________________________________________________

h. Functional limitations/restriction (specify length of time or maximum weight)

Sitting ___________ Standing ___________ Walking ___________ Lifting ___________ Carrying ___________ Bending ___________

i. Expected duration of restrictions/limitations ________ __________________________________________________________

j. Current height

weight

Part IV: FACTORS AFFECTING RECOVERY

General fitness ________________________________________________________________________________________

Addiction _____________________________________________________________________________________________

Diet _________________________________________________________________________________________________

Work environment ______________________________________________________________________________________

Home environment _____________________________________________________________________________________

Past medical history ____________________________________________________________________________________

Pre-existing conditions __________________________________________________________________________________

Family history of present condition _________________________________________________________________________

Has the patient previously had a similar condition?

Yes

If yes, specify date of initial onset _____________________

Bcbs Attending Physician Statement General

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