Claim Form - The Ccpoa Benefit Trust Fund Page 3
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ATTENDING PHYSICIAN’S STATEMENT
PATIENT’S NAME
ADDRESS (Street, City, State, Zip)
AGE
DIAGNOSIS
(DESCRIBE COMPLICATIONS, IF ANY)
SICKNESS
1. NATURE AND ORIGIN OF:
INJURY
CONFIRMED BY X-RAY?
YES
NO
2. WHEN DID SYMPTOMS FIRST APPEAR OR
DATE . . . . . . . . . . . . /. . . . . . . . . . . . . /. . . . . . . . . . . . . . . . .
ACCIDENT HAPPEN?
MO.
DAY
YR.
3. WHEN DID PATIENT FIRST CONSULT YOU
FOR THIS CONDITION?
DATE . . . . . . . . . . . . /. . . . . . . . . . . . . /. . . . . . . . . . . . . . . . .
MO.
DAY
YR.
4. HOW DID CONDITION ORIGINATE?
5. HAS PATIENT EVER HAD SAME OR SIMILAR
YES
DESCRIBE CONDITION:
CONDITION? (IF “YES”, STATE WHEN AND
DESCRIBE.)
NO
6. DESCRIBE ANY OTHER DISEASE OR INFIRMITY
AFFECTING PRESENT CONDITION.
CLOSED REDUCTION?
DATE . . . . . . . . . . . . /. . . . . . . . . . . . . /. . . . . . . . . . . . . . . . .
7. GIVE DATE AND NATURE OF SURGICAL OR
MO.
DAY
YR.
OPEN REDUCTION?
OBSTETRICAL PROCEDURE, IF ANY. (DESCRIBE
FULLY AND GIVE APPROACH USED IF MORE THAN
NATURE OF PROCEDURE:
METAL FIXATION?
ONE IS POSSIBLE.)
APPROACH USED:
OFFICE
DATE . . . . . . . . . . . . /. . . . . . . . . . . . . /. . . . . . . . . . . . . . . . .
MO.
DAY
YR.
HOSPITAL
NATURE OF TREATMENT:
8. GIVE DATE OF TREATMENT, AND NATURE
HOME
OF TREATMENT OTHER THAN SURGICAL.
9. IS PATIENT STILL UNDER YOUR CARE FOR
YES
THIS CONDITION? IF DISCHARGED, GIVE DATE,
NO
DISCHARGE DATE . . . . . . . . . . . . /. . . . . . . . . . . . . /. . . . . . . . . . . . . . . . .
RECOVERED?
YES
NO
AND DEGREE OF RECOVERY.
MO.
DAY
YR.
HOSPITAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10. IF PATIENT HOSPITALIZED, GIVE NAME AND
ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . STATE . . . . . . . . . . . . . . .
ADDRESS OF HOSPITAL.
FROM . . . . . . . . . . . . /. . . . . . . . . . . . . /. . . . . . . . . . . . . . . . .
THROUGH
. . . . . . . . . . . . /. . . . . . . . . . . . . /. . . . . . . . . . . . . . . . .
MO.
DAY
YR.
MO.
DAY
YR.
11. HOW LONG WAS OR WILL PATIENT BE
FROM . . . . . . . . . . . . /. . . . . . . . . . . . . /. . . . . . . . . . . . . . . . .
THROUGH
. . . . . . . . . . . . /. . . . . . . . . . . . . /. . . . . . . . . . . . . . . . .
CONTINUOUSLY TOTALLY DISABLED?
MO.
DAY
YR.
MO.
DAY
YR.
12. HOW LONG WAS OR WILL PATIENT BE
FROM . . . . . . . . . . . . /. . . . . . . . . . . . . /. . . . . . . . . . . . . . . . .
THROUGH
. . . . . . . . . . . . /. . . . . . . . . . . . . /. . . . . . . . . . . . . . . . .
PARTIALLY DISABLED?
MO.
DAY
YR.
MO.
DAY
YR.
13. IF PATIENT IS DISABLED ON DATE YOU COMPLETE
YES
RETURN TO WORK DATE . . . . . . . . . . . . /. . . . . . . . . . . . . /. . . . . . . . . . . . . . . . .
MO.
DAY
YR.
THIS FORM, IS THERE A RETURN TO WORK DATE?
(IF “YES”, GIVE RETURN TO WORK DATE.)
NO
PHYSICIAN’S SIGNATURE
DEGREE
COMPLETE ADDRESS
DATE
TELEPHONE
MUST BE FURNISHED UNDER AUTHORITY OF SECTION 6109 OF THE IRS CODE
INDIVIDUAL PRACTITIONER’S S.S. NUMBER
ALL OTHERS - EMPLOYER I.D. NUMBER
Policy Number:
Form No. 000640-CCPOA (3-11)
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