Form Bn-658-0212 - Group Disability Claim Page 4
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4american Fidelity assurance Company
Mail to:
AFES Benefits Department
P.O. Box 25160
Oklahoma City, OK 73125-0160
Local: (405) 523-5025
toll Free: 1-800-662-1113
Fax: 1-800-818-3453
attEnding PhysiCian’s statEMEnt
See front page for fraud warnings.
Name of Patient:
Date of Birth:
Social Security Number:
Account Number:
Diagnosis: (including complications)
ICDA Code:
d
i
a
Is disability due to injury or sickness arising out of or in the course of patient’s employment?
r Yes
r No
g
n
o
Is disability the result of pregnancy? r Yes
r No
If yes, type of delivery: ___________________________
s
i
Date pregnancy was diagnosed? ____/____/____ Date of delivery:(if delivered) ____/____/____ Expected date of delivery? ____/____/____
s
When did symptoms first appear or accident happen?
Date patient first consulted you for this condition?
h
______/______/______
______/______/______
i
s
Has the patient ever had the same or similar condition?
r Yes
r No
If yes, indicate when and describe:
t
o
r
Was the patient referred to you?
r Yes
r No
If yes, full name and address of referring physician:
y
Frequency of treatment:
r Monthly
r Weekly
r Other
Date of next appointment : _______/______/______
Nature of treatment being rendered (including surgery and any medications being prescribed)
t
r
E
List all dates of treatment or medical attention since the disability began:
a
t
M
Is patient still under your regular care for this condition?
r Yes
r No
If no, please explain and provide name of the current treating physician:
E
n
t
Admitted: _____/_____/_____ Discharged: _____/_____/_____
Has the patient been confined to a hospital?
r Yes
r No
If yes, give admit and discharge dates along with name and address of hospital.
Admitted: _____/_____/_____ Discharged: _____/_____/_____
Name:___________________________________________________ Address: ___________________________________________________
Dates of total disability: (unable to work) From: ____________________ Through: ____________________
Disabled from: Patient’s Job
r Yes
r No
Any other work
r Yes
r No
P
Dates of partial disability?
From: ____________________ Through: ____________________
r
o
If the patient is currently disabled, what is the anticipated length of disability?
g
n
r 1-2 Months
r 2-3 Months
r 3-6 Months
o
r 6-12 Months
r More than 12 Months
r Permanent
s
i
When, in your opinion, will the patient recover sufficiently to return to work?
s
Functional Limitations that render your patient totally disabled:
i
M
P
a
Current Treatment Plan:
i
r
M
E
n
t
s
Attending Physician’s Name: (print)
Specialty:
Telephone #:
Fax #:
(
)
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)
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Street Address:
City:
State:
Zip Code:
Signature:
Federal Tax ID #:
Date:
Email address:
BN-658-0212
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