Physician Statement Stroke Claim Form printable pdf download

Colorado Bankers Life Insurance Company®

Attn: Claims Department

5990 Greenwood Plaza Blvd., Suite 325

Greenwood Village, CO 80111

800.367.7814

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Fax: 855.777.5433

Email:

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ATTENDING PHYSICIAN STATEMENT

FOR CRITICAL CONDITION ACCELERATED BENEFIT

PHYSICIAN STATEMENT

STROKE CLAIM FORM

This form is provided to you, the physician, to be completed on behalf of your patient. The completion of this form is necessary for your patient to be

considered for Accelerated Benefits under their policy. Attached please find authorization for the release of any medical information. All sections must

be fully answered and this form must be signed and dated. If you have any questions, please contact the Claims Department.

Patient name ____________________________________ Social Security Number ______ - _____ - ______ Date of birth _____ / ______ / ______

1. Diagnosis ____________________________________________________________________________________________________________

a. Date condition first diagnosed__________________________ b. Date patient advised of condition______________________________

c. Prognosis _____________________________________________________________________________________________________

_____________________________________________________________________________________________________________

d. Course of treatment ____________________________________________________________________________________________

_____________________________________________________________________________________________________________

2. Was diagnosis of Cerebrovascular accident made?

 yes

 no

If YES, on what date did the CVA occur? ______ / _______ / _______

What was the cause of the stroke (if known): ___________________________________________________________________________

_______________________________________________________________________________________________________________

Please describe the residual neurological deficits: ________________________________________________________________________

_______________________________________________________________________________________________________________

How long has the neurological deficits persisted? ________________________________________________________________________

_______________________________________________________________________________________________________________

Please list the information of who made the diagnosis:

Name _________________________________________________________________________________________________________

Address______________________________________________ City_________________________ State ____________ Zip_________

Phone ( _______ ) - _________________________

3. Please provide a copy of the CT Scan or MRI results (if available).

4. Please describe and include dates of any predisposing disorders or risk factors (including family history) your patient had for this condition:

________________________________________________________________________________________________________________________

PS-Stroke 09-15 Page 1 of 3

Physician Statement Stroke Claim Form

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