Form Abj10364-2 - Cancer / Specified Disease / Icu / Heart / Stroke Claim - 2012 Page 2
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4INSTRUCTIONS FOR FILING TRANSPORTATION AND LODGING CLAIMS:
Please attach receipts for lodging and transportation (common carrier).
TRANSPORTATION AND LODGING
Name of Patient:
Condition Treated:
Dates of Travel:
Dates of Lodging:
Home Address:
Location of Treatment
ATTENDING PHYSICIAN’S STATEMENT
Patient’s Name:
Age:
1.
Diagnosis:
2.
If condition is due to pregnancy, what is expected delivery date? Date
/
/
MO/DAY/YR
3.
When did symptoms first appear or accident happen?
Date
/
/
MO/DAY/YR
4.
When did patient first consult you for this condition? Date
/
/
MO/DAY/YR
5.
Has patient ever had same or similar condition? (If “yes,” state when and describe.)
Yes
No
6.
Describe any other diseases or infirmity affecting present condition.
7.
Nature of surgical or obstetrical procedure, if any (describe fully).
8.
Is patient unable to perform job duties?
Yes
No If yes, from
through
9a. What specific job duties is patient unable to perform?
9b. Specific RESTRICTIONS (What the patient should not do and why). Please quantify in hours, weight, etc.
9c. Specific LIMITATIONS (What the patient cannot do and why).
10. If retired or unemployed which activities of daily living (ADLs) is patient unable to perform?
11. Date patient last examined by you:
Frequency of visits:
weekly
monthly
other
12. Is patient:
ambulatory
bed confined
house confined
other
13. If patient is hospitalized, give name and address of hospital.
Hospital:
City:
State:
14a. Date admitted:
/
/
Date discharged:
/
/
MO/DAY/YR
MO/DAY/YR
14b. When do you expect patient to resume partial duties?
/
/
Full duties?
/
/
MO/DAY/YR
MO/DAY/YR
14c. If patient is unemployed or retired, on what date would you expect a person of like age, gender and good health to resume his/her normal and
necessary activities?
/
/
MO/DAY/YR
15. Is condition due to injury or sickness arising out of patient’s employment?
Yes
No
If “yes,” explain.
Name and address of referring physician if any.
Name:
Address:
City:
State:
Zip
16. Have you completed paperwork for any other insurance company?
Yes
No
Social Security Disability?
Yes
No
Remember, it is a crime to fill out this form with facts you know are false or to leave out facts you know are relevant and important. Check to
be sure that all information is correct before signing. Please refer to page 3 for notice specific to your state.
PHYSICIAN VERIFICATION
Signed:
, MD
Date:
/
/
Phone: (
)
MO/DAY/YR
Street Address:
City/Town:
State/Province:
Zip Code:
ASSIGNMENT OF BENEFITS (n/a in New Hampshire)
I request that American Heritage Life Insurance Company send benefits to someone other than me. Please send benefits available to the name and
address shown below:
________________________________________________________
Name
Address
Provider’s Tax Identification Number
City
State
Zip
Relationship
Signature of Policy Owner
Date
ABJ10364-2
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