Physician Statement Form – Fill Out and Use This PDF

The Physician Statement Form is a document that both primary insured individuals and examining physicians are required to complete, providing detailed patient information, medical diagnosis, and any relevant treatment before submitting a claim to an insurance company. Specifically, it involves providing patient's personal and physician's information, a comprehensive medical diagnosis, including the ICD-9 codes for insurance purposes, and details surrounding the patient's medical condition that may affect their ability to travel. To ensure you have all necessary details accurately filled out, click the button below to start filling out your Physician Statement Form.

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Physician Statement Form PDF Details

When navigating the complexities of insurance claims, especially those related to health and the ability to travel, the Physician Statement Form serves as a critical document. This form bridges the gap between medical assessments and insurance decisions, aiming to streamline the process for both the insurer and the insured. It requires completion by two primary parties: the primary insured person, who provides personal and insurance-related details, and the examining physician, who offers comprehensive patient information, including diagnosis, the necessity for travel cancellation or interruption, and a medical professional’s insight into the patient's condition. This information includes the patient's full name, date of birth, contact details, and specific data about the examining physician such as their name, specialty, and contact information. Additionally, the form inquires about the physician's relationship to the patient (whether they are the primary care provider), the patient’s primary diagnosis, any underlying conditions, and a detailed history of office visits prior to the insurance purchase date. Crucially, the examining doctor must indicate whether the patient’s medical condition necessitated the cancellation or interruption of travel plans and provide a signature to verify the information’s accuracy. This form is not only a crucial component in the claims process for Allianz Global Assistance and similar entities but also acts as an essential tool in ensuring that decisions regarding travel insurance claims are made with a thorough understanding of the insured individual's medical situation.

Question	Answer
Form Name	Physician Statement Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	statement form physician, physician's statement disability form, form physician statement, attending physician s statement form

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Physician Statement Form

To be completed by Primary Insured

Primary Insured’s Name:

Policy Number:

Insurance Purchase Date:

To be completed by Examining Physician

PATIENT INFORMATION

Patient’s Name: ___________________________________
Date of Birth: _____ / ________ / _____________

Street Address: ___________________________________	City: ______________	State: ____		Zip Code: _______


Physician Information
Examining Physician’s Name: ________________________	Specialty: _______________________________________


Street Address: ___________________________________	City: ______________	State: ____		Zip Code: _______


Phone: (______) ______ -- ____________	Fax: (______) ______ -- ____________



Are you the patient’s primary care physician?
			No
	Who is this patient’s primary care physician?
	Name: __________________________________________
Yes	Phone: (_____) _______ -- ___________

	Was the patient referred to you by the primary care
	physician?
	Yes			No

E-mail to: claimsinquiry@allianzassistance.com

Mail to: Allianz Global Assistance, P.O. Box 72031, RICHMOND, VA 23255-2031

Call: @(claim_inquiry_phone) Fax to: 804-673-1469. We are available 24 hours a day.

Plan administered by AGA Service Company

Patient’s Diagnosis:
Did you perform an actual examination?	Yes	No

Date of the exam: ____ / _____ / _________

Please indicate the primary diagnosis for which you examined the patient:

__________________________________________________________________________________________________

ICD-9 Code: _______________

Date symptoms first appeared or accident occurred: ____ / _____ / _________
Is this condition a complication of an underlying condition?	Yes (specify below)	No

__________________________________________________________________________________________________

Please list the dates of the patient’s office visits in the 120 days before the insurance purchase date, noted above. Circle the dates where you treated the patient for the above stated condition.

____ / _____ / ___________	____ / _____ / ___________	____ / _____ / ___________	____ / _____ / ___________
____ / _____ / ___________	____ / _____ / ___________	____ / _____ / ___________	____ / _____ / ___________

Did you advise the trip be cancelled or interrupted due to the patient’s medical condition?
Yes Date: ___ / ___ / _________			No
Please explain why you made this recommendation.		Please explain why you did not make this recommendation.
Provide details on the circumstances and medical diagnosis		Provide details on the circumstances and medical diagnosis
of the patient that you consider relevant to the insured’s		of the patient that you consider relevant to the insured’s
decision to cancel or interrupt their trip due to injury or		decision to cancel or interrupt their trip due to injury or
illness.		illness.
________________________________________________		________________________________________________
________________________________________________		________________________________________________
________________________________________________		________________________________________________
________________________________________________		________________________________________________

________________________________________________		________________________________________________


If the patient is the insured, on what date did he/she become medically unable to travel?			___ / ___ / ________

By my signature and stamp below, I hereby certify that the above is true and correct

Physician Signature: _________________________________________________ Date ____/____/______

Physician Stamp:

E-mail to: claimsinquiry@allianzassistance.com

Mail to: Allianz Global Assistance, P.O. Box 72031, RICHMOND, VA 23255-2031

Call: @(claim_inquiry_phone) Fax to: 804-673-1469. We are available 24 hours a day.

Plan administered by AGA Service Company

How to Edit Physician Statement Form Online for Free

Filling out the physician statement of mental incompetence form document is not hard with our PDF editor. Keep up with these particular actions to get the document ready instantly.

Step 1: The initial step would be to click the orange "Get Form Now" button.

Step 2: You're now equipped to update physician statement of mental incompetence form. You possess a wide range of options thanks to our multifunctional toolbar - it's possible to add, remove, or modify the information, highlight its specific parts, and conduct similar commands.

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example of fields in attending physician statement form

Write down the details in Who is this patients primary care, Name, Yes, Phone, Was the patient referred to you by, Yes, and Email to.

Completing attending physician statement form stage 2

The software will request data to automatically fill in the section Patients Diagnosis Did you perform, Date of the exam, Yes, Please indicate the primary, ICD Code, Date symptoms first appeared or, Is this condition a complication, Yes specify below, Please list the dates of the, Did you advise the trip be, and Yes Date.

attending physician statement form Patients Diagnosis Did you perform, Date of the exam, Yes, Please indicate the primary, ICD Code, Date symptoms first appeared or, Is this condition a complication, Yes specify below, Please list the dates of the, Did you advise the trip be, and Yes Date blanks to fill out

The field Please explain why you made this, Please explain why you did not, If the patient is the insured on, By my signature and stamp below I, Physician Signature Date, and Physician Stamp is for you to include both sides' rights and obligations.

stage 4 to filling out attending physician statement form

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Step 4: It can be better to prepare copies of your file. There is no doubt that we will not display or view your particulars.

Physician Statement Form – Fill Out and Use This PDF

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