Physician Statement Form – Fill Out and Use This PDF

The Physician Statement Form can be used to document a patient's medical history. It is an optional form and you are not required by law to fill it out, but it does provide extra information about the patient.

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Physician Statement Form PDF Details

A physician statement form is a document that is filled out by a medical doctor to provide information about a patient's health. This form can be used for various reasons, including insurance claims and disability applications. The physician statement form contains important information about the patient's current health condition and past medical history. It is important to make sure that the information on the form is accurate and up-to-date. Any mistakes on the form could potentially lead to problems down the road.

Here, you will discover quite a few information regarding physician statement form PDF. It's going to provide you with the assumed time it will require you to prepare the form and several further details.

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.

These areas are inside the PDF document you will be filling in.

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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Physician Statement Form – Fill Out and Use This PDF

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