Form Lc 7135 1 PDF Details

Understanding the LC-7135-1 form, also known as the Attending Physician's Statement of Disability, is crucial for individuals navigating through the insurance claims process with the Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. This comprehensive document serves as a critical piece of communication between the patient's physician and the insurance company, aiming to establish the veracity of a disability claim. It requires detailed information about the patient, including basic identification details, diagnosis, treatment history, and an assessment of the patient's current physical or psychiatric impairments that affect their ability to work. Not only does it ask for the primary and secondary diagnoses, including ICD-9 codes, but it also delves into specifics regarding treatment dates, patient progress, and anticipated duration of the impairment. Physicians are tasked with evaluating the patient's capability to perform everyday activities such as standing, walking, sitting, and more intricate tasks that might be limited due to their condition. This form plays an essential role in the claim process, as the detailed medical information provided helps the insurance company make an informed decision regarding disability benefits.

QuestionAnswer
Form NameForm Lc 7135 1
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshartford lc 7135 form, hartford physician statement, the hartford attending physician form lc 7135 10, the hartford lc 7135 10 form

Form Preview Example

HARTFORD LIFE INSURANCE COMPANY

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY ATTENDING PHYSICIAN'S STATEMENT OF DISABILITY

Clear Form

To be completed by the Employee

Name of patient

 

Social Security Number

 

D.O.B

 

 

 

 

 

Address of patient

 

 

 

 

 

 

Street

City

State or Province

 

ZIp Code or Postal Code

 

 

 

Employer's name (and division, if applicable)

I hereby authorize release of information on this form by the below

SIgned (Patient)

 

 

 

named physician for the purpose of claim processing.

 

 

Date:

To be completed by the Attending Physician (The patient is responsible for the completion of this form without expense to the Company)

Patient's condition is the result of:

 

Illness

 

Injury

 

 

 

 

Pregnancy

Height

 

 

Weight

 

 

 

If pregnancy, what is the expected date of delivery?

Month

 

 

 

 

 

 

Day

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is condition due to illness or an injury that is work related?

 

 

 

Yes

 

 

 

No

 

 

 

 

 

DIAGNOSIS

Primary diagnosis:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ICD-9 Code:

 

Secondary diagnosis(es):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ICD-9 Code(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Subjective symptoms:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Test Results (list all results, or enclose test):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Test:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

Results:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Test:

 

 

 

 

 

 

Date:

 

 

 

Results:

 

 

Physical examination findings:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If pregnancy, indicate LMP date: Month

 

 

 

 

 

 

Day

 

 

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TREATMENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date you first treated this patient:

 

 

 

 

 

 

 

 

Date you first treated this patient for this condition:

 

 

 

 

 

Date of onset of this condition:

 

Date of most recent treatment:

 

 

How often has patient been seen/treated?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of next office visit:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has patient been referred to any other physician?

 

 

 

Yes

 

 

No If "Yes," Date(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name and address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specialty:

Nature of treatment for this condition:

Has surgery been performed? Yes No Was patient hospitalized for this condition?

Name and address of hospital(s):

If "Yes,"

Date:

 

Procedure:

 

 

CPT Code:

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No If "Yes," Date(s) admitted:

 

 

 

Date(s) discharged:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Progress (Please check one.):

Recovered

Improved

Unchanged

Retrogressed

LC-7135-1

ATTENDING PHYSICIAN'S STATEMENT OF DISABILITY (Side two)

IMPAIRMENT

If the patient's ability to perform any of the following activities is limited by his/her disorder, please describe the extent of the limitation and its expected duration.

Standing:

Walking:

Sitting:

Lifting/carrying:

Reaching/working overhead:

Pushing:

Pulling:

Driving:

Keyboard use/repetitive hand motion:

If any other activities are limited, please specify the activities and the limitations:

If the patient's vision is impaired, please describe the extent of the impairment:

Do you believe the patient is competent to endorse checks and direct the use of the proceeds thereof?

Yes

No

What is the psychiatric impairment (if applicable)?

Inadequate information to make assessment.

Essentially good functioning in all areas. Occupationally and socially effective.

Slight difficulty in occupational functioning, but generally functioning well. Has some meaningful interpersonal relationships. Moderate impairment in occupational functioning. Limited in performing some occupational duties.

Major impairment in several areas--work, family relations. Avoidant behavior, neglects family, is unable to work. Inability to function in almost all areas

Date patient became unable to work due to this impairment? Month

 

 

Day

 

 

 

Year

 

If physical or psychiatric limitations exist, how long do you feel limitations will last?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attending Physician's Name:

 

 

 

 

 

 

 

 

 

 

Telephone #

 

 

 

 

 

 

 

 

 

 

(Please print or type.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

License No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FAX #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SS# or E.I.N.#:

 

 

Degree:

 

 

 

 

 

 

Specialty:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

City:

 

 

 

 

 

 

State:

 

 

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature:

 

 

 

 

 

 

 

 

 

 

Date signed:

 

 

 

 

 

 

LC-7135-1

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1. To start off, when completing the the hartford form lc 7135 12, start out with the part that has the subsequent fields:

Filling out segment 1 of lc 7135 11

2. Once the last section is completed, it is time to add the necessary particulars in Test, Test, Physical examination findings, Date, Date, Results, Results, If pregnancy indicate LMP date, Month, Day, Year, TREATMENTS, Date you first treated this patient, Date you first treated this, and Date of onset of this condition allowing you to go to the third step.

Step # 2 for completing lc 7135 11

3. The following segment is rather simple, Has surgery been performed Yes No, CPT Code, Was patient hospitalized for this, No If Yes Dates admitted, Dates discharged, Name and address of hospitals, Progress Please check one Recovered, Improved, Unchanged, and Retrogressed - these blanks must be completed here.

Stage no. 3 in submitting lc 7135 11

Always be very attentive when filling in Improved and Retrogressed, because this is where a lot of people make errors.

4. The following subsection will require your involvement in the following areas: IMPAIRMENT If the patients ability, Standing, Walking, Sitting, Liftingcarrying, Reachingworking overhead, Pushing, Pulling, Driving, and Keyboard userepetitive hand motion. Make certain to fill in all requested information to move forward.

Liftingcarrying, IMPAIRMENT If the patients ability, and Sitting in lc 7135 11

5. Lastly, the following last part is what you need to finish prior to finalizing the document. The blank fields here are the next: Keyboard userepetitive hand motion, If any other activities are, If the patients vision is impaired, Do you believe the patient is, What is the psychiatric impairment, Inadequate information to make, Essentially good functioning in, Slight difficulty in occupational, Moderate impairment in, Major impairment in several, Inability to function in almost, Date patient became unable to work, Day, Year, and If physical or psychiatric.

How you can fill out lc 7135 11 part 5

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