Spousal Accident Disability Claim Form Page 4
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1
2
3
4American Fidelity Assurance Company
Mail to:
AFES Benefits Department
SPOUSAL
P.O. Box 25160
ACCIDENT
Oklahoma City, OK 73125-0160
Toll Free: 1-800-662-1113
DISABILTY
Fax:
1-800-818-3453
ATTENDING PHYSICIAN’S STATEMENT
See front page for fraud warnings.
Name of Patient:
Date of Birth:
Social Security Number:
Account Number:
Diagnosis: (including complications)
ICDA Code:
D
I
A
G
N
O
Is disability due to injury arising out of or in the course of patient’s employment?
o Yes
o No
S
I
S
Is disability due to an accident?
o Yes
o No
H
When did accident happen?
Date patient first consulted you for this condition?
I
______/______/______
______/______/______
S
T
Has the patient ever had the same or similar condition?
o Yes
o No
If yes, indicate when and describe:
O
R
Y
Was the patient referred to you?
o Yes
o No
If yes, full name and address of referring physician:
Frequency of treatment:
o Monthly
o Weekly
o Other
Date of next appointment : _______/______/______
Nature of treatment being rendered (including surgery and any medications being prescribed)
T
R
E
List all dates of treatment or medical attention since the disability began:
A
T
M
Is patient still under your regular care for this condition?
o Yes
o No
If no, please explain and provide name of the current treating physician:
E
N
T
Admitted: _____/_____/_____ Discharged: _____/_____/_____
Has the patient been confined to a hospital?
o Yes
o No
Admitted: _____/_____/_____ Discharged: _____/_____/_____
If yes, give admit and discharge dates along with name and address of hospital.
Name:___________________________________________________ Address: ___________________________________________________
Dates of total disability: (unable to work) From: ____________________ Through: ____________________
P
Dates of partial disability?
From: ____________________ Through: ____________________
R
O
If the patient is currently disabled, what is the anticipated length of disability?
G
o 1-2 Months
o 2-3 Months
o 3-6 Months
N
O
o 6-12 Months
o More than 12 Months
o Permanent
S
When, in your opinion, will the patient recover sufficiently to return to work?
I
S
Functional Limitations that render your patient totally disabled:
I
M
P
A
Current Treatment Plan:
I
R
M
E
N
T
S
Attending Physician’s Name: (print)
Specialty:
Telephone #:
Fax #:
(
)
-
(
)
-
Street Address:
City:
State:
Zip Code:
Signature:
Federal Tax ID #:
Date:
Email address:
BN-723-1114
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