Routine Pregnancy Claim Form Page 4
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4American Fidelity Assurance Company
Mail to: AWD Benefits Department
P.O. Box 268898 | Oklahoma City, OK 73126-8898
toll Free Phone # 1-800-437-1011
toll Free Fax # 1-888-243-3453
sECtioN 3: AttENDiNG PhysiCiAN’s stAtEMENt
Name of Patient:
Date of Birth:
Social Security Number:
Diagnosis:
ICDA Code:
D
i
A
T ype of delivery: ________________________________________________ _ ________________________________________________________________
G
N
o
s
Date pregnancy was diagnosed? ____/____/____
i
s
Date of delivery: (if delivered)
___/____/_____
____/____/____
When did symptoms first appear?
h
Date patient first consulted you for this condition?
____/____/____
i
s
Was the patient referred to you?
Yes
No
If yes, full name and address of referring physician: _________________________________________
r
r
t
o
____________________________________________________________________________________________________________________________
r
y
_____________________________________________________________________________________________________________________________
Has the patient been confined to a hospital?
Yes
No
r
r
t
r
E
Admitted: _____/_____/_____ Discharged: _____/_____/_____
A
t
If yes, give admit and discharge dates along with name and address of hospital.
M
Name: _______________________________________________________________________________________________________________________
E
N
Address:______________________________________________________________________________________________________________________
t
P
r
o
G
N
o
Dates of total disability: (unable to work) From: ______________________________________ Through: ________________________________________
s
i
s
Attending Physician’s Name: (print)
Degree:
Telephone #:
Fax #:
(
)
-
(
)
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Street Address:
City:
State:
Zip Code:
Signature:
Federal Tax ID #:
Date:
BN-728 AWD
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