Physician Statement Form – Fill Out and Use This PDF

Updated: Nov 9, 2026

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

How to Fill Out Physician Statement Form

Physician Statement Form at a glance

What it is: The Physician Statement Form has a part to be completed by Primary Insured and a part to be completed by Examining Physician.

Who signs: Sign on Physician Signature, enter the Date and add the Physician Stamp to certify that it is true and correct.

A filled-in Physician Statement Form example: a physician completes the statement

Physician Statement Form example filled out, example: a physician completes the statement — Dr. Ana Sample completes the Physician Statement Form for one patient. The patient is the insured, and the exam took place 41 days before the insurance purchase date. The picture shows both pages, and none of its entries is real. Dr. Sample is not the patient's primary care physician, so No is marked under "Are you the patient's primary care physician?", and the Name and Phone of the patient's primary care physician are entered. The patient was referred to Dr. Sample by the primary care physician, so Yes is marked. Dr. Sample performed an actual examination, so Yes is marked, and the condition is not a complication of an underlying condition, so No is marked. The trip was advised cancelled, so Yes and the Date are entered, and the explanation for No stays empty.

How to fill out Physician Statement Form, box by box

The primary insured's part

Enter the Primary Insured's Name, Policy Number and Insurance Purchase Date.

Patient information

Under Patient Information, enter the Patient's Name, Date of Birth, Street Address, City, State and Zip Code.

Physician information

Under Physician Information, enter the Examining Physician's Name, Specialty, Street Address, City, State, Zip Code, Phone and Fax.

Primary care physician and referral

Enter Yes or No under "Are you the patient's primary care physician?", enter the Name and Phone under "Who is this patient's primary care physician?" and enter Yes or No under "Was the patient referred to you by the primary care physician?"

Patient's diagnosis

Under Patient's Diagnosis, enter Yes or No under "Did you perform an actual examination?", and enter the Date of the exam, the primary diagnosis for which you examined the patient and the ICD-9 Code.

Enter the Date symptoms first appeared or accident occurred, and enter Yes or No under "Is this condition a complication of an underlying condition?"

Office visits

List the dates of the patient's office visits in the 120 days before the Insurance Purchase Date and circle the dates where you treated the patient for the stated condition.

Trip cancelled or interrupted

Under "Did you advise the trip be cancelled or interrupted due to the patient's medical condition?", enter Yes and a Date. Then explain why you made this recommendation, with details on the circumstances and medical diagnosis of the patient that you consider relevant to the insured's decision to cancel or interrupt their trip due to injury or illness.

Under "Did you advise the trip be cancelled or interrupted due to the patient's medical condition?", enter No. Then explain why you did not make this recommendation, with details on the circumstances and medical diagnosis of the patient that you consider relevant to the insured's decision to cancel or interrupt their trip due to injury or illness.

Medically unable to travel

If the patient is the insured, enter the date for "on what date did he/she become medically unable to travel?"

Physician signature and stamp

Sign on Physician Signature, enter the Date and add the Physician Stamp to certify that it is true and correct.

If your situation is different

E-mail to, Mail to or Fax to

E-mail to claimsinquiry@allianzassistance.com, mail to Allianz Global Assistance, P.O. Box 72031, RICHMOND, VA 23255-2031, or fax to 804-673-1469.

Sources

[1] Physician Statement Form (the served file; no issuer file found) (the Official source link on this page).