Pearl Carroll Disability Forms 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.

QuestionAnswer
Form NamePearl Carroll Disability Claim Form
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other namespearl and carroll disability forms, pearl carroll disability printable, pearl and carroll, print pearl and carroll forms

Form Preview Example

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 the List of Providers/Hospitals that have 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 Providers Statement.

Please see that the completed form is returned to:

Pearl Carroll & Associates LLC

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.

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 6/2014

CSEA MEMBERS DISABILITY INCOME FORM

Member Name: ________________________________________________________

Date of Birth: ___________________________

Social Security # ______________________________________ Female

Male

 

Mailing Address: ______________________________________________

 

__________

 

(No.)

(Street)

 

 

(Apt No.)

_______________________________________________________________

 

(City or Town)

 

(State)

 

(Zip Code)

Telephone No.: Home: (

)______________________

Employer (

)______________ Height: ________ Weight ________

Employers Name: ___________________________________________________________

Normal Number of Hours Worked Per Week: ________

Employers 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.

Day

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**

1

CSEA DI ed 6/2014

CSEA MEMBERS DISABILITY INCOME FORM

Members Name ___________________________________ Members 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:

 

 

 

 

 

 

 

 

 

 

2

CSEA DI ed 6/2014

CSEA MEMBERS 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.

PLEASE NOTE: 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

 

Latham, NY 12110

 

Fax # 518-640-8105

 

3

CSEA DI ed 6/2014

 

Release From: ___________________________________________________________

 

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: Keais Records Service Inc. 1010 Lamar, Suite 300 Houston, TX 77002

Please see that the completed form is returned to:

Pearl Carroll & Associates LLC

12 Cornell Road

Latham, NY 12110

Fax # 518-640-8105

4

CSEA DI ed 6/2014

MEDICAL PROVIDERS 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.PATIENTS NAME: ______________________________________________ SOCIAL SECURITY NO.: __________________

 

(First)

(Middle)

(Last)

 

 

 

 

 

 

 

DATE OF BIRTH: _____/_____/______

2.

CURRENT MEDICAL CONDITION(s):

 

 

 

(MO) (DAY)

(YEAR)

 

PRIMARY DIAGNOSIS: __________________________________

ICD-9 CM CODE: ________________

 

SECONDARY DIAGNOSIS: _____________________________

ICD-9 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 PATIENTS 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)

1

CSEA DI ed 6/2014

MEDICAL PROVIDER’S STATEMENT

PATIENTS 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)

 

 

 

 

ANY PERSON WHO KNOWINGLY AND WITH THE 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

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

Latham, NY 12110

Fax # 518-640-8105

2

CSEA DI ed 6/2014

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