Attending Physician's Statement Submission Form
This form is designed for employees to obtain an attending physician's statement for disability claims. It must be completed by both the employee and the physician with specific medical details. Ensure all necessary information is accurately filled out to prevent delays in processing.
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How do I fill this out?
Filling out this form requires accurate information regarding the patient's condition and treatment history. You'll need to gather input from both the patient and the attending physician. Follow the detailed instructions provided within the form to ensure proper completion.
How to fill out the Attending Physician's Statement Submission Form?
1
Read the form carefully before starting.
2
Fill out the patient's personal information accurately.
3
Provide detailed medical history and findings.
4
Ensure both the employee and physician complete their respective sections.
5
Submit the completed form as instructed.
Who needs the Attending Physician's Statement Submission Form?
1
Employees seeking disability benefits from their employer.
2
HR departments needing to verify medical claims.
3
Attending physicians required to provide statements for patients.
4
Insurance companies assessing disability claims.
5
Legal representatives handling case files for clients.
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What are the instructions for submitting this form?
To submit this form, email it to GBInformationUpload@thehartford.com or fax it to 833-357-5153. Alternatively, you can mail it to The Hartford, P.O. Box 14869, Lexington, KY 40512-4869. Ensure all sections are completed before submission to avoid delays.
What are the important dates for this form in 2024 and 2025?
Be aware of important dates related to your submission in 2024 and 2025. While specific deadlines may vary based on your employer's policies, ensure all forms are submitted promptly to avoid delays. Check with your HR for any updates regarding submission timelines.
What is the purpose of this form?
The purpose of this form is to provide an official report from a physician regarding a patient's health condition necessary for disability benefits. It establishes the medical basis for a patient's claim, ensuring that the insurance provider has accurate information. By completing this form, both the employee and physician contribute to a transparent process that aids in the prompt assessment of disability claims.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: The name of the patient as recorded.
- 2. Date of Birth: The birth date of the patient.
- 3. Insured ID Number: The identification number assigned to the insured individual.
- 4. Patient Condition: The reason for the patient's medical issue, classified under sickness, injury, or pregnancy.
- 5. Treatment History: Details regarding the patient's treatment and any medical findings.
- 6. Physician Information: Information about the physician, including name, specialty, and contact number.
- 7. Restrictions/Limitations: Any restrictions or limitations the physician prescribes for the patient.
What happens if I fail to submit this form?
Failure to submit this form can lead to delays in processing disability claims, affecting the applicant's benefits. It’s crucial to ensure the form is completed fully and accurately before submission. Missing or incomplete information may necessitate further inquiries, extending the claim review process.
- Delays in Claims Processing: Incomplete submissions can slow down the approval of benefits.
- Denial of Claims: Failure to provide necessary medical documentation may result in denial.
- Need for Resubmission: You may be required to fill out the form again, causing more delays.
How do I know when to use this form?
- 1. Applying for Disability Benefits: Essential when requesting benefits for health-related work absences.
- 2. Updating Medical Information: Required if there are changes in the patient’s condition or treatment.
- 3. Verification by Insurers: Needed by insurance companies to validate claims.
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Follow the submission instructions provided within the form for guidance.
Can this form be completed online?
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What details are needed from the physician?
The physician must provide their observations, treatment history, and any relevant medical findings.
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