Physician Statement Forms Make 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.

QuestionAnswer
Form NamePhysician Statement Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesallianz physician form, attending physician statement pdf, attending physician s statement form, form physician statement

Form Preview Example

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

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