Cigna Form Physician PDF Details

Understanding the Cigna Physician Form is crucial for anyone navigating the complexities of life insurance claims or dealing with disability matters. This detailed form serves multiple purposes, including serving as a critical communication tool between healthcare professionals and insurance companies. It outlines the insured individual's medical condition, treatment history, and physical or mental impairments that could influence work capabilities. Importantly, the form adheres to stringent regulations to prevent insurance fraud, highlighting the legal implications for those who might contemplate submitting false information. Specific sections demand thorough completion by the healthcare provider, which, coupled with medical documentation, supports the claim's validity. Furthermore, the form aligns with the Genetic Information Nondiscrimination Act of 2008 (GINA), ensuring that genetic information is neither requested nor required, thereby protecting the patient's privacy. Recognizing the implications for residents in various states, the form includes particular fraud warnings applicable to locales with unique legal stances on insurance fraud, enhancing its relevance across the United States.

QuestionAnswer
Form NameCigna Form Physician
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namescigna disability statement, disability form cigna, form physician disability statement, attending physician statement

Form Preview Example

Physician’s Statement

Life Insurance Company of North America

 

Connecticut General Life Insurance Company

 

Cigna Life Insurance Company of New York

 

Great-West Healthcare Administered by Cigna

GB-608066 Rev. 12/2012

FRAUD WARNING: Any person who, knowingly and with intent to defraud any insurance company or other

person: (1) files an application for insurance or statement of claim containing any materially false information; or

(2)conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act. For residents of the following states, please see the last page of this form: California,

Colorado, District of Columbia, Florida, Kentucky, Maryland, Minnesota, New Jersey, New York, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas or Virginia.

PHYSICIAN’S STATEMENT OF DISABILITY (PLEASE PRINT)

Please complete all relevant sections as thoroughly as possible and include medical documentation to support your findings.

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by the GINA Title II from requesting or requiring genetic information of employees or their family members. In order to comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. "Genetic Information," as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

THIS SECTION IS TO BE COMPLETED BY THE PATIENT/INSURED

NAME

ADDRESS

CITY

TELEPHONE

 

 

EMPLOYER NAME

 

 

SOCIAL SECURITY NUMBER

STATE

ZIP CODE

GROUP POLICY NUMBER

OCCUPATION

 

DATE OF BIRTH

 

 

 

THE REMAINING SECTIONS OF THIS FORM ARE TO BE COMPLETED BY YOUR PHYSICIAN(S)

1.DIAGNOSIS (Including any complications)

(a)Diagnosis (Include ICD-9 or DSM IV-TR Code)

(b)Subjective symptoms

(c)Objective findings (Please attach copies of current X-rays, EKG’s, Laboratory Data and any clinical findings as applicable.)

(d) Are symptoms consistent with the clinical findings?

Yes

No, explain

 

(e)

Is illness work related?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(f)

If pregnancy please indicate:

 

LMP:

EDC:

 

Actual Delivery:

 

 

 

 

 

 

 

 

 

 

 

 

2. DATES OF TREATMENT

 

 

Month

Day

Year

(a) Date patient first visited you for this accident/illness:

Month Day Year

(b)Date patient first unable to work due to this accident/illness:

(c)List frequency & date(s) patient was examined for this accident/illness:

Month Day Year

(d)Date of last visit:

3.NATURE OF TREATMENT (Including Surgery & Medications prescribed, if any)

Month

Day

Year

Month

Day

Year

(a) Hospitalization on:

THROUGH

Month

Day

Year

(b) Surgery on:

 

 

Type of Surgery:

 

 

 

 

 

 

(c) Name and Address of Hospital

 

 

 

(d)Medications

Type

Dosage

GB-608066 Rev. 12/2012

4.PHYSICAL LIMITATIONS / IF APPLICABLE: In an 8-hour work day is your patient able to:

0 hours

up to 2.5 hours

up to 5.5 hours

greater than 5.5 hours

Climb

Balance

Stoop

Kneel

Crouch

Crawl

Reach

Walk

Sit

Stand

Cardiac - If applicable (American Heart Association)

Class 1 - No Limitation

Class 2 - Slight Limitation

Class 3 - Marked Limitation

Class 4 - Complete Limitation

Blood Pressure (last visit)

Please indicate the maximum level of ability (sedentary, light, medium, heavy) of your patient to:

 

 

Lift

 

Carry

 

Push

 

 

Pull

Sedentary = 10 lbs. maximum, walking occasionally.

Light = 20 lbs. maximum, 10 lbs. frequently

Medium = 50 lbs. maximum, 25 lbs. frequently, up to 10 lbs. constantly.

Heavy - 100 lbs. maximum, 50 lbs. frequently, 20 lbs. constantly.

5.MENTAL IMPAIRMENT / IF APPLICABLE - Please complete the following (incomplete information will delay claim processing): Axis I:

Axis II:

Axis III:

Axis IV:

Axis V: Current GAF:

 

Highest GAF in past year:

 

Baseline:

Additional Comments:

 

 

 

6.

RETURN TO WORK STATUS

Patient’s Regular Occupation

Any Other Occupation

When was patient able to go to work?

Full-time

 

 

 

 

Full-time

 

 

 

 

 

Part-time

 

/

 

/

 

Part-time

 

/

 

/

 

 

 

Mo.

Day

Yr.

 

Mo.

Day

Yr.

 

 

 

 

 

 

 

7. REMARKS

Physician Name (Please Print):

Degree & Specialty:

Address: (Street, City, State, Zip Code)

Telephone Number:

Federal Tax ID #:

Physician Signature:

Date:

GB-608066 Rev. 12/2012

GB-608066 Rev. 12/2012

IMPORTANT CLAIM NOTICE

California Residents: 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 Residents: 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 settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

District of Columbia Residents: 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 Residents: 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.

Kentucky Residents: Any person who knowingly and with 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 thereto commits a fraudulent insurance act, which is a crime.

Maryland Residents: 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.

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

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

New York Residents: 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 shall also be subject to a civil penalty not to exceed $5000 and the stated value of the claim for each such violation.

Oregon Residents: Any person who knowingly and with intent to defraud any insurance company or other

person: (1) files an application for insurance or statement of claim containing any materially false information; or,

(2)conceals for the purpose of misleading, information concerning any material fact, may have committed a fraudulent insurance act.

Pennsylvania Residents: 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.

Rhode Island Residents: 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.

Tennessee Residents: 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 Residents: 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.

Virginia Residents: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits application or files a claim containing a false or deceptive statement may have violated state law.

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This PDF requires particular details to be filled out, so make sure to take the time to fill in precisely what is expected:

1. It is recommended to complete the cigna disability form properly, so be careful when working with the areas containing these particular fields:

cigna disability statement conclusion process clarified (portion 1)

2. Right after completing this section, go to the next stage and fill in all required particulars in these blank fields - c List frequency dates patient, d Date of last visit, Month Day Year, NATURE OF TREATMENT Including, Month Day Year, Month Day Year, a Hospitalization on, b Surgery on, c Name and Address of Hospital, Month Day Year, THROUGH, Type of Surgery, Medications, Type, and Dosage.

cigna disability statement conclusion process detailed (part 2)

3. Completing hours, up to hours, up to hours, greater than hours, Climb, Balance, Stoop, Kneel, Crouch, Crawl, Reach, Walk, Sit, Stand, and Please indicate the maximum level is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Ways to prepare cigna disability statement stage 3

4. Filling out RETURN TO WORK STATUS, When was patient able to go to work, REMARKS, Patients Regular Occupation, Any Other Occupation, Fulltime, Parttime, Day, Fulltime, Parttime, Day, Physician Name Please Print, Degree Specialty, Address Street City State Zip Code, and Telephone Number is key in this fourth stage - make sure you spend some time and fill out every single blank!

Stage # 4 of filling out cigna disability statement

5. This last point to finalize this form is essential. Make sure you fill in the displayed fields, for instance Physician Signature, GB Rev, and Date, prior to using the pdf. If not, it could result in an unfinished and probably incorrect document!

GB Rev, Date, and Physician Signature in cigna disability statement

You can easily get it wrong when filling out the GB Rev, hence make sure that you reread it prior to when you submit it.

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