Fillable Initial Credit/closed End Monthly Outstanding Balance Disability Claim Form (Page 3 of 4) in pdf

D. DOCTOR’S STATEMENT

(TO BE FURNISHED WITHOUT EXPENSE TO THE INSURANCE COMPANY)

PLEASE PRINT

PATIENT’S FULL NAME

DIAGNOSIS (CODE(S))

ICD-9

CPT

DSM III

CURRENT DIAGNOSIS

LIST THE NAMES OF ALL PRESCRIBED MEDICATIONS FOR THIS DIAGNOSIS

GIVE EXACT DATES OF TOTAL DISABILITY (UNABLE TO WORK)

GIVE EXACT DATES OF PARTIAL DISABILITY

His/Her Occupation

FROM

Any Occupation

IN YOUR EXPERT OPINION, HOW WOULD YOU QUALIFY THIS PATIENT

IF TEMPORARILY DISABLED, HOW MUCH LONGER DO YOU EXPECT THE PATIENT TO BE DISABLED

Permanently Disabled

Temporarily Disabled

Non-Disabled

1-2 months

3 months

6 months

Longer than 9 months

Undetermined

PHYSICAL IMPAIRMENTS (AS DEFINED IN FEDERAL DICTIONARY OF OCCUPATIONAL TITLE)

Class 1 - No limitation of functional capacity; capable of heavy work; no restrictions. (0-10%)

Class 2 - Medium manual activity. (15-30%)

Class 3 - Slight limitation of functional capacity; capable of light work. (35-55%)

Class 4 - Moderate limitation of functional capacity; capable of clerical/administrative (sedentary) activity. (60-70%)

Class 5 - Severe limitation of functional capacity; incapable of minimum (sedentary) activity. (75-100%)

IS CONDITION DUE TO PREGNANCY

IF YES, DESCRIBE COMPLICATIONS

ESTIMATED DATE OF DELIVERY

Yes

WHEN DID SYMPTOMS FIRST APPEAR

WAS DISABILITY CAUSED BY AN ACCIDENT

IF YES, DATE OF ORIGINAL ACCIDENT

IF YES, DESCRIBE ACCIDENT

Yes

HAS PATIENT EVER HAD SAME OR SIMILAR CONDITION

GIVE DATES OF TREATMENT FOR SIMILAR CONDITION (MM/DD/YY)

Yes

DESCRIBE SAME OR SIMILAR CONDITION

GIVE NAMES, ADDRESSES, AND PHONE NUMBERS OF OTHER TREATING PHYSICIANS (ATTACH ADDITIONAL SHEET IF NECESSARY)

DATES OF TREATMENT

FREQUENCY OF VISITS

Weekly

Monthly

Other (specify)

FIRST VISIT

LAST VISIT

NEXT VISIT

HAS PATIENT BEEN HOSPITALIZED

NAME OF HOSPITAL

Yes

If yes,

FROM

THROUGH

STREET ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER

(

)

DATE PERFORMED

DID PATIENT HAVE SURGERY

IF YES, DESCRIBE SURGERY

Yes

IS PATIENT STILL UNDER YOUR CARE FOR THIS CONDITION

IF PATIENT IS STILL UNDER YOUR CARE,

IF NOT, GIVE DATE PATIENT WAS RELEASED TO RESUME WORK

GIVE ESTIMATED DATE WHEN

Yes

PATIENT WILL RESUME WORK

PROGNOSIS/COMMENTS (HAS PATIENT PROGRESSED)

“I hereby certify that the above described information is based upon reasonable medical probability, and is true and correct to the best of my knowledge and belief.”

STREET ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER

FAX NUMBER

(

)

(

)

ATTENDING PHYSICIAN’S NAME (PLEASE PRINT)

ATTENDING PHYSICIAN’S SIGNATURE

MEDICAL ID NUMBER

DEGREE

DATE

FORM MUST BE FULLY COMPLETED AND SIGNED OR STAMPED BY DOCTOR’S OFFICE

For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a

false or fraudulent claim for payment of a loss is subject to criminal and civil penalties

CA residents only: For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent

claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

CO residents only: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of

defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance

company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for

the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall

be reported to the Colorado division of insurance within the department of regulatory agencies.

DC residents only: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other

person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim

was provided by the applicant.

FL residents only: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application

containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

KY residents only: Any person who knowingly and with intent to defraud any insurance company, or other person files a claim for insurance 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. HIGH LIMIT AD - No statements made by the applicant may be changed without his written consent.

MD residents only: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully

presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NJ residents only: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

NM residents only: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information

in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

OK residents only: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of

an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

PA residents only: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or

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 and subjects such person to criminal and civil penalties.

RI residents only: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information

in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

TX residents only: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines

and confinement in state prison.

VA residents only: *This notice is not applicable to life and health insurance.

WA residents only: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding

the company. Penalties include imprisonment, fines, and denial of insurance benefits.

C1030-0412

Page 3 of 4