Claim Form - Burba Insurance Services Page 3
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3ATTENDING PHYSICIAN'S STATEMENT
TO BE COMPLETED BY THE PATIENT’S ATTENDING PHYSICIAN
(THE INSURED IS RESPONSIBLE FOR THE COMPLETION OF THIS FORM WITHOUT EXPENSE TO THE COMPANY.)
1.
Policy Holder: _____________________________________________________________________ Policy Number: _____________________
2.
Name of Patient: _________________________________________________________________________________ Age: _______________
3.
Other Insurance, including Medicaid: ______________________________________________________________________________________
4.
Diagnosis (Please use ICD 9 codes.): __________________________When did symptoms first appear or accident happen? ____________________
5.
When did the patient first consult you for this condition? _______________________________ If the patient previously had medical attention, please
provide the physician’s/hospital’s name and address.__________________________________________________________________________
If the claim is for pregnancy, please give due date. _______________________
6.
Has the patient ever had the same or a similar condition? o Yes o No (If yes, state when and describe.) __________________________________
7.
Describe any other disease or infirmity affecting present condition. _______________________________________________________________
8.
List surgical procedure(s), if any, and include the date of the procedure(s) and the charges. (Please use current CPT codes.) ____________________
________________________________________
___________________________________________________________________
9.
List the dates of treatment and the charges for each visit. _____________________________________________________________________
10. If the patient was hospitalized, please give the name and address of the hospital and dates of confinement. ___________________________________
____________________________________________________________ Give number of days of ICU confinement. _____________________
11. Was Private Duty Nursing required and authorized by you? oYes o No If yes, give dates. ____________________________________________
12. Is the patient still under your care for this condition? o Yes o No If discharged, please give date. _____________________ If the patient has been
referred to another physician, please give that physician’s name and address. _______________________________________________________
_________________________________________________________________________________________________________________
13. Please give dates the patient was unable to work due to this condition. From _________________To ______________ If the patient was released to
light duty due to this condition, please give dates. From _______________To ________________ Was patient unable to perform two or more
ADL’s (Activities of Daily Living) due to this condition? o Yes o No If so, which ones? ______________________________________________
14. Has patient ever been treated for a heart attack, heart trouble or any abnormal condition of the heart; cancer; or diabetes prior to this time?
o Yes o No If yes, please advise when and name and address of doctor/hospital treating patient. _______________________________________
15. Please list conditions and corresponding dates for which you previously treated this patient within the last five years.___________________________
________________________________________________________________________________________________________________
DATE:
PHYSICIAN’S NAME (PRINTED):
SIGNATURE:
PHONE NUMBER:
_____________________________________________________________________________________________________ __(
)____________________
STREET ADDRESS:
CITY:
STATE:
ZIP:
____________________________________________________________________________________________________________________________________
TAX IDENTIFICATION NUMBER OR INDIVIDUAL SOCIAL SECURITY NUMBER (REQUIRED BY LAW):
____________________________________________________________________________________________________________________________________
FRAUD STATEMENT
Any person who knowingly and with intent to defraud any insurance company or other persons, files a statement of claim containing any
materially false information, or conceals for the purpose of misleading, information concerning any fact, material thereto, commits a fraudulent
insurance act, which is a crime, subject to criminal prosecution and civil penalties.
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