Pearl Carroll Disability Claim Form – Fill Out and Use This PDF

The Pearl Carroll Disability Claim Form is used to apply for disability benefits.

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Pearl Carroll Disability Claim Form PDF Details

The Pearl Carroll Disability Claim Form is a document used to claim disability benefits. The form can be filled out online or offline, and it requires detailed information about the claimant's medical history and current condition. The form is reviewed by a disability insurance company, who will then make a determination on whether the claimant is eligible for benefits. Filing a disability claim can be complex, so it's important to understand all of the requirements beforehand.

Listed below are some facts you may want to examine just before you start dealing with the pearl carroll disability claim form.

Question	Answer
Form Name	Pearl Carroll Disability Claim Form
Form Length	7 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 45 sec
Other names	pearl carroll forms, pearl carroll workers comp insurance forms, pearl carroll csea disability, pearl carroll disability insurance forms

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STATEMENT OF RECOVERY OR RETURN TO WORK

DISABILITY INCOME CLAIM INSTRUCTIONS

(PLEASE DETACH THIS NOTICE BEFORE MAILING AND KEEP FOR FUTURE REFERENCE)

Please answer all questions on the Member Statement on your Disability Income claim form

Please provide a complete List of Providers/Hospitals that treated you for this disability.

Date and sign both the Members Statement and the Authorization for Release of Information.

Please have your Medical Provider complete both pages of the Medical Provider’s Statement.

Please see that the completed form is returned to:

Pearl Carroll & Associates LLC

Disability Claims Unit

12 Cornell Road

Latham, NY 12110

If you recover or return to work, please notify Pearl Carroll & Associates immediately by completing and mailing this statement to the above address or emailing to Customercare@PearlCarroll.com.

If you have any questions concerning your request for Disability Income benefits, you may call the Office of the Administrator at 1-800-697-2732. The fax number is 518-640-8105. Please note that we will not confirm receipt of a fax for 24 - 48 hours.

Name: _______________________________________________________________________________

Mailing Address: _______________________________________________________________________

_______________________________________________________________________

Social Security No.: ______-______-________

Policy G-11628

I recovered:

I returned to work

Other (I.E. Returned to work light duty, another job etc):

Date:

Month/Day/Year

Date: _______________________ Signature: ___________________________________________

Email Address: __________________________________________________________________________________

CSEA DI ed 10/2016

CSEA MEMBER’S DISABILITY INCOME FORM

CLAIM TYPE:		Member Disability		Spouse-Coverage Disability				Non-Disabling Injury
		Hospital Benefit						Survivor Benefit
Member Name:	____________________________________					Date of Birth: ___________________________
Social Security # _____________________________________							Male	Female
Spouse Name:	____________________________________					Date of Birth: ___________________________
Social Security # ______________________________________							Male	Female
Mailing Address: _____________________________________________________________________									__________
		(No.)	(Street)						(Apt No.)
	_______________________________________________________________
		(City or Town)		(State)				(Zip Code)
Telephone No.: Home: (		)______________________			Em ployer (		) ________________ Height: ________			Weight ________
Employer’s Name: ___________________________________________________________								Normal Number of Hours Worked Per Week: ________
Employer’s Street Address: ______________________________________________________________________________________
		(No.)		(Street)			(City or Town)		(State)	(Zip Code)

Email Address: ____________________________________________________________________________________________________

What is the nature of your disability?__________________________________________________________________________________

Is disability work related? Yes	No		If yes, please attach a copy of the Employee Accident Report signed by manager
Is disability due to an Injury? Yes		No		If “Yes”, when? _______/______/________
						Mo .	Da y	Year
Where did it happen?__________________________________________________________
How did it happen? _______________________________________________________________
Date first treated for this disability:		_____/_____/_______
		Mo.	Day	Year
Date First Unable to Work: ______/______/______				Date Last Worked: ______/_______/_______
Mo.	Day	Year		Mo.	Day	Year

Have you attempted to return to your occupation since the date disability began? (If so, give details)

If returned to work or recovered, give date: _____/_____/______			Returned to work: Full Time:
Mo.	Day	Year	Part Time:
			If Part Time, # of hours per day _______
If not returned, when do you expect to? _____/_____/______
Mo.	Day	Year

Are your working a second job? If so, please provide the name and address of the company and the hours you are working.

**If disability is due to a Motor Vehicle Accident, please attach MV-104A Police Report**

** If treated in hospital or Urgent Care Center, please attach a copy of your discharge papers**

CSEA DI ed 10/2016

CSEA MEMBER’S DISABILITY INCOME FORM

Member’s Name ___________________________________ Member’s Social Security #________________________

Names and addresses of providers consulted and any other providers seen for treatment.

PLEASE PRINT – If you need more space, you may attach a sheet of paper with the additional names, addresses, and phone numbers. Be sure to include all providers, as any missing may delay your claim.

PHYSICIANS:

Name:			Name:

Address:			Address:

City:			City:

State:	Zip:		State:	Zip:

Phone:			Phone:

Name:			Name:

Address:			Address:

City:			City:

State:	Zip:		State:	Zip:

Phone:			Phone:

Name:			Name:

Address:			Address:

City:			City:

State:	Zip:		State:	Zip:

Phone:			Phone:

		HOSPITALS
Name:			Name:

Address:			Address:

City:			City:

State:	Zip:		State:	Zip:

Phone:			Phone:

		PHARMACIES
Name:			Name:

Address:			Address:

City:			City:

State:	Zip:		State:	Zip:

Phone:			Phone:

CSEA DI ed 10/2016

CSEA MEMBER’S DISABILITY INCOME FORM

Member Name _______________________________________ Member’s Social Security #__________________________

Please state your occupation: ________________________________________________

**Please attach a copy of your official job description**

Please fully describe all the duties of your occupation at the time you stopped working including the percentage of time spent on

each activity:

_____________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

What are your daily activities?________________________________________________________________

_________________________________________________________________________________________________________

Are you receiving or will you be eligible to receive benefits from:	Workman’s Compensation?	Yes	No
	Pension Plan?	Yes	No
	Another Group Insurance Plan?	Yes	No
	Individual Disability Income Policy?	Yes	No
	Social Security Disability?	Yes	No

If “Yes” insert policy number, claim number and address of insurance company or organization providing such benefits and amount of payment.

Policy No.

Claim No.

Name and Address

Amount of Payment

I declare that the answers on Page 1, Page 2 and Page 3 of this form are complete and true to the best of my knowledge and belief. I also agree that I will advise the New York Life Insurance Company of my return to any type of work and that I will return any payments to which I am not entitled by reason of my return to work or termination of my disability.

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 five thousand dollars and the stated value of the claim for each such violation.

Date: _____________	Member’s Signature _______________________________________________
MO/ DAY/YEAR	The Member or someone on his/her behalf must sign here and on the
	Authorization for Release of Information Form.
	Please see that the completed form is returned to:
	Pearl Carroll & Associates LLC
	12 Cornell Road – Disability Unit
	Latham, NY 12110
	Fax # 518-640-8105 or email to Customercare@PearlCarroll.com
	3

CSEA DI ed 10/2016

	Authorization for Release of Information
TO:	All providers of medical services and supplies, pharmacy related service organizations, prescription history database

suppliers, employers, insurance institutions, the Social Security Administration and other organizations.

I authorize release to New York Life Insurance Company or their representative, Pearl Carroll & Associates LLC, any independent claim administrators, consulting health professionals, pharmacy related service organizations and utilization review organizations with whom New York Life has contracted, information concerning health care advice, treatment or supplies provided the patient (including that related to mental illness and/or AIDS/ARC/HIV) and prescription records. This information will be used to evaluate claims for benefits.

In Oklahoma, the information authorized for release may include records which may indicate the presence of a communicable or non-communicable disease.

This authorization may be used for a period of 24 months from the date signed below unless sooner revoked. I may revoke this authorization at any time by notifying New York Life in writing at the address given on this form. My revocation will not be effective to the extent New York Life or any other person has already disclosed or collected information or taken other action in reliance on it. The information New York Life obtains through this authorization may become subject to further disclosure. For example, New York Life may be required to provide it to an insurance regulatory or other government agency. In this case, the information may no longer be protected by the rules governing this authorization.

A photocopy of this authorization and request form shall be as valid as the original. I know that I may request a copy of this authorization.

_____________________________________________	_________________________________
Patient’s Signature	Date
_____________________________________________	_________________________________
Print Name	Social Security No
______________________________________________	__________________________________
Address	City,	State	Zip
______________________________________________	__________________________________
Email Address	Phone Number

Medical Records Release to: Datafied Inc. 1210 N. Jefferson St. Suite P Anaheim, CA 92807

Please see that the completed form is returned to:

Pearl Carroll & Associates LLC

12 Cornell Road – Disability Unit

Latham, NY 12110

Fax # 518-640-8105 or email to Customercare@PearlCarroll.com

CSEA DI ed 10/2016

MEDICAL PROVIDER’S STATEMENT

(The patient is responsible for the completion of this form without expense to the Company)

Notice to Provider: Thank you in advance for your cooperation in completing this form on behalf of your patient identified below. We will consider this information in conjunction with other information gathered to determine the claimant’s eligibility for benefits according to his or her specific contract with us. We will periodically request that you provide updated information, records and chart notes to enable our evaluation of a continuing claim. In order for us to expedite our consideration of your patient’s claim, please fully answer each question and sign and date the form where indicated.

1.PATIENT’S NAME: ______________________________________________ SOCIAL SECURITY NO.: __________________

	(First)	(Middle)	(Last)
				DATE OF BIRTH: _____/_____/______
2.	CURRENT MEDICAL CONDITION(s):				(Mo) (Day)	(Year)
	PRIMARY DIAGNOSIS: __________________________________			ICD-10 CM CODE: _____________
	SECONDARY DIAGNOSIS: _____________________________			ICD-10 CM CODE: _____________
3.	DATE THAT SYMPTOMS FIRST APPEARED OR ACCIDENT HAPPENED:				______/_____/_______
					(Mo) (Day)	(Year)
4.	DATE THAT PATIENT FIRST CONSULTED YOU FOR THIS CONDITION:				______/_____/_______
					(Mo) (Day)	(Year)
5.	DATE YOU LAST TREATED THE PATIENT:				______/_____/_______
					(Mo) (Day)	(Year)
6.	IS THIS CONDITION RELATED TO PATIENT’S EMPLOYMENT?			YES	NO
7.	WAS PATIENT REFERRED TO YOU BY ANOTHER PRACTITIONER?			YES	NO

(If “Yes”, please provide the name and address of that practitioner): __________________________________________________

______________________________________________________________________________________________________________

8.OBJECTIVE FINDINGS (Include x-rays, lab results and clinical findings. If pregnancy, also give LMP and EDC):

____________________________________________________________________________________________________

9. HAS PATIENT BEEN HOSPITALIZED? YES NO (If “YES”, provide reason, hospital name and dates of

confinement): ________________________________________________________________________________

10.NATURE OF TREATMENT CURRENTLY BEING PROVIDED OR PLANNED: (Include dates and type of surgery

and any medications prescribed if applicable): ___________________________________________________

_______________________________________________________________________________________

11.HAVE YOU REFERRED THE PATIENT TO ANOTHER PRACTITIONER? YES NO (If “Yes”, please provide the name and address of all applicable physicians or ): ________________________________________________________

____________________________________________________________________________________________________

12.IN YOUR OPINION IS THE PATIENT ABLE TO WORK AT THIS TIME? YES NO

IF “NO”, WHEN DO YOU EXPECT THAT THE PATIENT WILL BE ABLE TO PERFORM SOME WORK?	______/_____/_______
	(Mo) (Day) (Year)

CSEA DI ed 10/2016

MEDICAL PROVIDER’S STATEMENT

PATIENT’S NAME: ______________________________________________ SOCIAL SECURITY NO.: ____________________

(First)

(Middle)

(Last)

13.IS THERE ANY TYPE OF JOB MODIFICATION OR ACCOMODATION THAT WOULD ENABLE THE PATIENT TO WORK

AT THIS TIME? YES NO (If “Yes”, please describe): _______________________________________

____________________________________________________________________________________________________

14.		BASED ON OBJECTIVE FINDINGS AND YOUR
MEDICAL OPINION:
a)	THE PATIENT WAS TOTALLY DISABLED FROM:	_____/_____/_____ THROUGH: _____/_____/_____
		(Mo.) (Day) (Year)	(Mo.) (Day) (Year)
b)	THE PATIENT WAS PARTIALLY DISABLED FROM:	_____/_____/_____ THROUGH: _____/_____/_____
		(Mo.) (Day) (Year)	(Mo.) (Day) (Year)

15.LIST ALL CURRENT RESTRICTIONS AND LIMITATIONS YOU HAVE PLACED ON THE ATIENT’S WORK AND PERSONAL

ACTIVITIES DUE TO HIS OR HER MEDICAL CONDITION (If none, indicate “NONE): ___________________________________

____________________________________________________________________________________________________

16. HAS THE PATIENT BEEN RELEASED FROM YOUR CARE? YES			NO
IF “YES” DATE RELEASED FROM YOUR CARE:		IF “NO”, DATE OF NEXT SCHEDULED TREATMENT OR EVALUATION:
______/_______/________			______/_______/_________
(Mo) (Day)	(Year)		(Mo) (Day)	(Year)

MEDICAL PROVIDER’S DECLARATION AND SIGNATURE

I declare that the answers on this statement are complete and true to the best of my knowledge and belief. I understand that periodic updates (including providing copies of medical records when requested) will be required in the event of a continuing claim.

_______________________________________ _____	__________________		_______________________
PROVIDER’S NAME (PLEASE PRINT)		Specialty	TELEPHONE NUMBER
_________________________________________________	___________________________________________________
STREET ADDRESS	CITY	STATE	ZIP CODE
_____________________________________________		_______________________
PROVIDER’S SIGNATURE		DATE SIGNED
Please return completed forms to:

Pearl Carroll & Associates LLC

12 Cornell Road – Disability Unit

Latham, NY 12110

Fax # 518-640-8105 or email to CustomerCare@PearlCarroll.com

CSEA DI ed 10/2016

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csea pearl carroll disability insurance blanks to consider

Fill out the Hospital Benefit, Survivor Benefit, Member Name, Date of Birth, Social Security, Male, Female, Spouse Name, Date of Birth, Social Security, Male, Female, Mailing Address, Street, and Apt No area with the details requested by the software.

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Describe the most essential information on the Is disability due to an Injury Yes, If Yes when, D a y Year, Where did it happen, How did it happen, Date first treated for this, Mo Day, Year, Date First Unable to Work Year, Mo Day, Date Last Worked Mo Day Year, Have you attempted to return to, If returned to work or recovered, Returned to work Full Time, and Mo Day Year part.

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When it comes to space CSEA MEMBERS DISABILITY INCOME FORM, Members Name Members Social, Names and addresses of providers, PLEASE PRINT If you need more, PHYSICIANS, Name, Address, City, State, Phone, Name, Address, City, State, and Zip, define the rights and obligations.

Filling in csea pearl carroll disability insurance part 4

End up by reading these sections and filling them in as required: CSEA MEMBERS DISABILITY INCOME FORM, Member Name Members Social, Please state your occupation, Please attach a copy of your, Please fully describe all the, each activity, and What are your daily activities.

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Pearl Carroll Disability Claim Form – Fill Out and Use This PDF

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