Combined Insurance Company Of America Instructions For Filing Accident And Claim Forms Page 3
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3ATTENDING PHYSICIAN’S STATEMENT — PLEASE PRINT
The patient is responsible for securing this form and for charges made for its completion.
patIeNt Name
date oF bIrth
(mm/dd/yyyy)
a) prImary
1. DIAGNOSIS OF PRESENT CONDITION
b) addItIoNal CoNdItIoNs or ComplICatIoNs
(speCIFIC medICal dIagNosIs)
C) obJeCtIve FINdINgs
(INCLUDING CURRENT X-RAYS, LABORATORY DATA AND ANY CLINICAL FINDINGS)
date
(mm/dd/yyyy)
2. IF CONDITION IS DUE TO PREGNANCY,
What Is the eXpeCted date oF
CoNFINemeNt?
a) the sICKNess FIrst appeared oN
a) the aCCIdeNt oCCurred oN
(mm/dd/yyyy)
(mm/dd/yyyy)
3. TO THE BEST OF MY KNOWLEDGE:
b) the patIeNt has had same or sImIlar CoNdItIoN
o
o
yes
No
please state WheN
AND DESCRIBE BELOW (#14) ____________________
(mm/dd/yyyy)
a) beeN reFerred to you?
(gIve Name oF reFerrINg physICIaN)
4. HAS THE PATIENT ...
b) beeN reFerred by you to a speCIalIst?
(gIve Name[s] oF physICIaN[s])
A) HOSPITAL IN-PATIENT ADMISSION
b) date oF dIsCharge
(mm/dd/yyyy)
(mm/dd/yyyy)
5. DATES OF CONFINEMENT
desCrIbe
6. NATURE OF TREATMENT
(e.g. date aNd type
oF surgery, treatmeNt INCludINg medICatIoN,
dosage aNd FreQueNCy
a) date oF FIrst vIsIt?
b) date oF latest atteNdaNCe?
(mm/dd/yyyy)
(mm/dd/yyyy)
7. DATES FOR PRESENT CONDITION
o
o
WeeKly?
moNtly?
other?
(speCIFy)
8. Were you aCtIvely supervIsINg
yes
No
patIeNt’s Care durINg Full perIod?
DESCRIBE BELOW (#14)
From
to
(mm/dd/yyyy)
(mm/dd/yyyy)
9. TO THE BEST OF YOUR KNOWLEDGE,
the patIeNt has beeN uNable to WorK
at oWN oCCupatIoN
From
to
(mm/dd/yyyy)
(mm/dd/yyyy)
10. THE PATIENT WILL BE ABLE TO PERFORM
some dutIes oF oWN oCCupatIoN
date
(mm/dd/yyyy)
11. IF STILL UNABLE TO WORK, GIVE
approXImate date patIeNt should be
able to returN to WorK
12. IF NOT GAINFULLY EMPLOYED, CAN
o
yes
__________________________
(speCIFy IF they CaN perForm all or some oF theIr usual daIly aCtIvItIes) _
he/she perForm hIs/her usual daIly
aCtIvItIes?
o
No
___________________________________________
(estImate Number oF WeeKs beFore possIble returN) _
desCrIbe
13. HOW DOES PRESENT CONDITION AFFECT
patIeNt’s abIlIty to WorK/preForm
usual aCtIvItIes? speCIFIC restrICtIoNs
(drIvINg, beNdINg, lIFtINg, etC.), raNge
oF motIoN oF aFFeCted area?
14. REMARKS. PLEASE PROVIDE COMMENTS
aNd Further detaIls WhICh you Feel
Would be helpFul.
Name oF atteNdINg physICIaN
speCIalty
telephoNe Number
(please prINt)
address
postal Code
sIgNature
date
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