Attending Physician Statement Metlife Form PDF Details

Navigating through insurance paperwork can often seem daunting, but understanding specific forms such as the Attending Physician Statement by MetLife is crucial for a seamless claim process. This form serves as a comprehensive tool for documenting a patient's medical condition, directly from the attending physician, to support disability claims. Start to finish, the document outlines clear instructions for both the patient (employee) and the attending physician. The patient section mandates essential details such as occupation, Social Security number, and an authorization for the physician to release medical information pertinent to the claim. Meanwhile, the physician's portion dives into the medical specifics—ranging from the diagnosis, treatment history, and prognosis, to an evaluation of the patient's physical and psychological capabilities. Each field is designed to furnish MetLife with all necessary information to make an informed decision regarding the disability claim. Beyond the clinical data, the form also includes a fraud warning, emphasizing the legal implications of submitting false or misleading information, tailored to both general and state-specific laws. Overall, the Attending Physician Statement MetLife form plays a pivotal role in bridging the gap between medical assessments and insurance claims, striving for a balance of detailed disclosure and patient confidentiality.

QuestionAnswer
Form NameAttending Physician Statement Metlife Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesmetlife attending physician statement form, 5320 statement, metlife 5320, metlife physician statement

Form Preview Example

ATTENDING PHYSICIAN STATEMENT

Instructions for completing the claim form:

1.Complete all applicable areas of the claim form.

2.Sign the claim form.

3.Fax this claim form to expedite your claim – retain original for your records.

Metropolitan Life Insurance Company

P.O. Box 14590

Lexington, KY 40511-4590

Fax: 1-800-230-9531

The following section must be completed and signed by the employee/patient. Occupation

Any fee for the completion of this form is the patient’s responsibility.

Name-MUST ANSWER

Social Security#

 

Employer-MUST ANSWER

Group Report #

 

MUST ANSWER

 

 

 

 

 

 

 

I hereby authorize my physician to release any information acquired in the course of examination or treatment.

Date of Birth

Signature of Employee__________________________________________

Date ____________________

 

 

 

 

 

 

The following section must be completed and signed by the attending physician.

The purpose of this report is to assist us in making a disability determination. Please complete all applicable sections of this form. A MetLife claim representative may telephone your office if additional information is needed.

History

Symptoms result from:  Injury

 Illness

Is condition work-related?

 Yes  No

Initial date of treatment ________________________________ Most recent date of treatment _____________________

Did you advise the patient to cease the above noted occupation?  Yes  No If Yes, Date __________________

Names and Phone Numbers of the providers the patient was referred to:

 

Name

Phone #

Name

Phone #

_________________________ _________________________ _________________________

________________________

Has patient been hospitalized?

 Yes  No

If Yes, Day Confined __________________ Through ______________

Name and address of facility

 

 

 

Diagnosis and Treatment

Primary ICD-9 _______ - __________________ Diagnosis __________________________________________________

Secondary ICD-9 _______ - _______________ Diagnosis __________________________________________________

Subjective Symptoms

________________________________________________________________________________________________________________

Objective Findings (Include copies/results of any x-rays, lab tests’, EKG’s, MRI’s, scans and office notes)

________________________________________________________________________________________________________________

Current and Recommended Treatment Plans ____________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

If surgery performed/anticipated, provide the following:

CPT-4 ________________________________________________ Procedure ____________________________ Date______________

Medications prescribed (names, dosages)

________________________________________________________ ___________________________________________________

________________________________________________________ ___________________________________________________

________________________________________________________ ___________________________________________________

Page 1 of 4

APSLTD 5320 (04/09) eF

Name of Employee: _____________________________________________ Social Security Number: __________________

Psychological Functions

Check applicable box below

Class 1 – Patient is able to function under stress and engage in interpersonal relations (no limitations)

Class 2 – Patient is able to function in most stress situations and engage in some interpersonal relations (slight limitations)

Class 3 – Patient is able to engage in only limited stress situations and engage in only limited interpersonal relations (moderate limitations)

Class 4 – Patient is unable to engage in stress situations and engage in interpersonal relations (marked limitations)

Class 5 – Patient has significant loss of psychological, physiological, personal and social adjustment (severe limitations) Remarks:

What stress factors or problems with interpersonal skills have affected patient’s ability to perform, the duties of his or her job?

Is patient competent to endorse checks and direct use of the proceeds?

 Yes  No

 

 

 

 

 

 

 

 

 

 

 

Physical Capabilities

 

 

 

 

 

 

 

 

(a) Patient’s ability to: (circle)

 

 

(b) Patient’s ability to: (circle)

 

 

 

 

 

 

Hours

 

 

 

(check)

 

Climb

Yes

No

Sit

0

1

2

3

4

5

6

7

8

 Continuously

 Intermittently

Twist/bend/stoop

Yes

No

Stand

0

1

2

3

4

5

6

7

8

 Continuously

 Intermittently

Reach above shoulder level

Yes

No

Walk

0

1

2

3

4

5

6

7

8

 Continuously

 Intermittently

Operate a motor vehicle

Yes

No

(c) Patient’s ability to lift/carry: (check)

 

 

 

 

 

 

 

 

Never

Occasionally Frequently Continuously

(d) Patient’s ability to perform repetitively: (circle)

 

0%

1-35%

36-66%

67-100%

 

Right Hand Left Hand

Up to 10 lbs.

Fine finger movements

Yes

No

Yes

No

11 to 20 lbs.

Eye/hand movements

Yes

No

Yes

No

21 to 50 lbs.

Pushing/pulling

Yes

No

Yes

No

51 to 100 lbs.

 

 

 

 

 

 

Over 100 lbs.

Dominant hand

 

R

 

L

 

(e)In your opinion, why is patient unable to perform job duties?

(f)Patient can work a total of_______________________________hours per day?

(g)Do you expect improvement in any area?

(If so please comment and give dates/timeframes.)

Cardiac

Functional Capacity (American Heart Association) Complete only if applicable.

 Class 1 (No Limitation)  Class 2 (Slight Limitation)  Class 3 (Marked Limitation)  Class 4 (Complete Limitation) Blood Pressure (latest reading) ________________ / ________________ as of (date) ________________ / ________________

Is patient in a cardiac rehabilitation program?

Prognosis

Have you advised patient to return to work?

 Yes

If Yes, date of return_____________________________  To regular occupation

 Full Time

 Part Time

 No

 To any other occupation

 Full Time

 Part Time

If Not, please explain

 

 

Any work/activity restrictions applicable (please be specific)

Rehab

Do you suggest that the patient become involved in any of the following? Please check as many as apply.

If so, was this discussed with the patient?

Yes No

 

 Physical Therapy

 Pain Management Program

 Vocational Rehabilitation

 Occupational Therapy

 Work Hardening Program

 Psychological Counseling

 Cardiac Rehabilitation

 Job Modification

 Other________________

Page 2 of 4

APSLTD 5320 (04/09) eF

Disability Claim Attending Physician Statement (Continued)

Name of Employee:

 

Social Security Number:

 

 

 

 

Fraud Warning:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim with materially false information or conceals for the purpose of misleading, information concerning any fact material there to may be guilty of committing a fraudulent insurance act. Please see below for special notice required by state law.

Alaska – A person who knowingly and with intent to injure, defraud or deceive an insurance company files a claim containing false, incomplete or misleading information may be prosecuted under state law.

Arizona – 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 loss is subject to criminal and civil penalties.

Arkansas, Louisiana, Maryland, West Virginia – 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.

California – For your protection California law requires the following to appear of 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.

Colorado – 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 life 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 respect to a settlement or award from insurance proceeds, shall be reported to the Colorado divisions of insurance within the department of regulatory agencies to the extent required by applicable law.

Delaware – Any person who knowingly and with the intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.

District of Columbia – 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.

Florida – 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.

Hawaii – For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

Idaho – Any person who knowingly and with the intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.

Indiana – A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.

Kentucky – Any person who knowingly and with the intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material there to commits a fraudulent insurance act, which is a crime.

Maine – It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Minnesota – A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

New Hampshire – A person who with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

Page 3 of 4

APSLTD 5320 (04/09) eF

Disability Claim Attending Physician Statement (Continued)

Name of Employee:

 

Social Security Number:

 

 

 

 

Fraud Warning (continued):

New Jersey – Any person who knowingly files a statement of claim containing false or misleading information is subject to criminal and civil penalties.

New Mexico – 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.

Ohio – A person who with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing false or deceptive statement is guilty of insurance fraud.

Oklahoma – WARNING: Any person who knowingly and with the 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.

Oregon – A person who knowingly and with intent to defraud an insurance company, files a claim containing false, incomplete or misleading information material to such claim, may be guilty of insurance fraud.

Pennsylvania – Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning a fact material there to commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Puerto Rico – Any person who knowingly and with the intention to defraud includes false information in an application for insurance or file, assist or abet in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousands dollars ($5,000), not to exceed ten thousands dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years.

Tennessee, Virginia, Washington – 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.

Texas – 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.

Physician

Name __________________________________________ Degree/Specialty _____________________________________

Street Address

 

City

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone #

 

 

 

 

Fax #

 

 

Tax ID #

 

 

 

Contact person if additional information is necessary

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

 

 

 

 

 

Date

 

 

 

 

Page 4 of 4

APSLTD 5320 (04/09) eF

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This PDF doc will need some specific information; in order to ensure correctness, please make sure to heed the following recommendations:

1. It's very important to fill out the metlife attending physician statement form accurately, so pay close attention while filling out the sections including these specific fields:

Filling in segment 1 in 5320 physician statement

2. When the prior selection of blank fields is completed, proceed to enter the relevant details in all these - Diagnosis and Treatment, Primary ICD Diagnosis , Secondary ICD Diagnosis , Subjective Symptoms, Objective Findings Include, Current and Recommended Treatment, If surgery performedanticipated, CPT Procedure Date, and Medications prescribed names.

Writing part 2 of 5320 physician statement

3. Throughout this part, examine Name of Employee Social Security, Psychological Functions Check, moderate limitations, Class Patient is unable to, What stress factors or problems, Is patient competent to endorse, Physical Capabilities b Patients, Continuously , Climb Twistbendstoop Reach above, check, Hours, Yes Yes Yes Yes, and No No No No. All these must be completed with greatest precision.

Completing part 3 of 5320 physician statement

4. Filling in Physical Capabilities b Patients, Continuously , Yes Yes Yes Yes, No No No No, c Patients ability to liftcarry, Never Occasionally Frequently, d Patients ability to perform, Fine finger movements Yes No Yes, Dominant hand, R L, e In your opinion why is patient, f Patient can work a total ofhours, If so please comment and give, Cardiac Functional Capacity, and Blood Pressure latest reading is essential in the fourth stage - you should definitely don't rush and be attentive with each and every blank area!

Completing segment 4 in 5320 physician statement

Concerning Physical Capabilities b Patients and If so please comment and give, be sure you don't make any mistakes in this section. These are considered the most significant fields in this PDF.

5. While you draw near to the conclusion of your file, you'll notice a couple extra requirements that need to be met. Particularly, Blood Pressure latest reading , Yes No Any workactivity, If Yes date of return To regular, Rehab Do you suggest that the, Pain Management Program Work, Vocational Rehabilitation , Page of , and APSLTD eF must all be done.

How you can fill out 5320 physician statement portion 5

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