Statement Of Claim - Cancer Insurance Page 2
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1
21.
Date of first symptoms
2. Date first consulted for this condition
3. Date condition diagnosed
4. Has patient ever been previously treated for cancer or related conditions
Yes
No If yes, Give date and diagnosis of prior advice and treatment for this condition
5. Name and address of physician who referred this patient
6. Name and address of hospital where services rendered
7. Name and address of nursing home where services rendered
8. For services
Date admitted
Date discharged
9. For services performed in
Date Admitted
Date discharged
performed in hospital
nursing home
10. Inclusive dates patient was confined in intensive care unit of hospital
11. Please provide names and addresses of other physicians currently treating patient
12. Diagnosis or nature of illness or injury requiring services or supplies
(Related diagnosis to procedure by reference to numbers 1.2.3. etc. in col. D)
1.
2.
3.
13.
A
B
C
D
E
Date of each
Place of service
Describe Surgical or medical procedures and other
DX No.
Charges
service
*See Codes
services or supplies furnished for each date given
(Explain unusual
Below
Procedure Code
(Explain unusual circumstances)
circumstances in Col. C)
Total Charges
Date
Physician’s Name (Print)
Signature
Degree
________ ________ ____________
________ _____________________
Individual Practitioners – SS#
All others – Employer Tax ID#
Street Address
City or Town
State or Province
Zip Code
*Place of Service Codes
1 - (H) = Inpatient Hospita1
4 – (H) Patient’s Home
7 – (NH) Nursing Home
O – (OL) Other Locations
2 – (OH) Outpatient Hospital
5 – Day care facility (PSY)
8 – (SNF) Skilled Nursing Facility
A – (IL) Independent Laboratory
3 – (O) Doctor’s Office
6 – Night Care (PSY)
9 – Ambulance
B – (ASC) Ambulatory Surgical Center
CL 4008 (05/02)
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