Form Twm-Cancerclaim-072710 - Cancer/specified Disease Claim Package Page 2
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4ATTENDING PHYSICIAN’S STATEMENT
1. Insured’s Full Name
2. Policy or Certificate Number
3. Patient’s Full Name
4. Patient’s Date of Birth
5. Are you being paid
Yes
Are you being paid
Yes
Are you being paid by
Yes If yes, what company?
by Medicare?
No
by Medicaid?
No
other health insurance?
No
6. Diagnosis? (Please use ICD 9 Codes)
7. When did symptoms first appear or accident happen?
8. When did the patient first consult you for this
condition?
9. If the patient previously had medical attention, please provide the physician’s/hospital’s name and address.
10. Has the patient ever had the same or similar condition?
11. Describe any other disease or infirmity affecting present condition.
Yes
No (If yes, state when and describe)
12. List surgical procedure(s), if any, and include the date of the procedure(s).
13. List the dates of treatment.
(Please use current CPT codes.)
14. If the patient was hospitalized, please give the name and address of the
15. Give number of days of ICU confinement.
hospital and dates of confinement.
16. Was Private Duty Nursing required and authorized by you?
17. Is the patient still under your care for this condition?
Yes
No
Yes
No (If yes, give dates)
If discharged, please give date ____________________
18. If the patient has been referred to another physician, please give the
19. Please give dates of total disability for this condition.
name and address.
From
To
20. 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?
Yes
No
If yes, please advise when and name and address of doctor/hospital treating patient.
21. Please list conditions and corresponding dates for which you previously treated this patient within the past five years.
Date
Physician’s Name – Print
Signature
Degree
Phone Number
(
)
Street address
City
State
Zip
Tax Identification Number
TWM-CancerClaim-072710
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