Transamerica attending physician statement form Yes No 18. How it works (AUL) by this Attending Physician and the facts and other matters contained in the foregoing are true and accurate to the best of the undersigned’s knowledge and belief. Employee Control Number Information. The bills need to have a breakdown of charges and include the diagnosis code. The patient is responsible for the completion of this form without expense to the insurance company. NOTE: If a psychiatric illness is present please complete the Attending Physician* Initial Statement form as well as the psychiatric section in the Psychiatric Condition Statement. 1240-0046 Expires: 08/31/2026. Regrettably, incomplete forms will compromise our ability to reach a decision about this . MPM31008TCA Details: yes No Transamerica Life Insurance Company Home Office: 4333 Edgewood Road NE Cedar Rapids, IA Attending Physician Statement APS is needed in order to continue Underwriting APS - Agent Attending Physician Statement is needed to be ordered by the agent. Critical Illness Attending Physician’s Statement: CL1476: Download: Critical Illness Claimant’s Statement: CL1477: Download: CriticalADVANTAGE Claimant’s Statement: CL1007: Download: Dealer/Nominee Transfer Form: Benefits Department | P. • The patient is responsible for completion of this form without expense to the company. com. If additional space is required, attach sheet(s) of paper - signed, dated and witnessed. All Transamerica companies identified are affiliated. Box 869097 Plano, TX 75086-9097 Claims fax: 866-224-6547 Claims email: Transamerica Premier Life Insurance Company Administrative Office: P. Easily add and highlight text, insert pictures, checkmarks, and symbols, drop new fillable fields, and rearrange or delete pages from your paperwork. Patient’s Full Name 4. Box 25160 | Oklahoma City, OK 73125-0160. NOTE TO PHYSICIAN. OMB No. claim. 2003. Ministry of Health Helping people stay healthy, delivering high-quality care when they need it and protecting the health system for future generations. Some companies, such as Humania, Health care professionals can access forms for UnitedHealthcare plans, including commercial, Medicaid, Medicare and Exchange plans in one convenient location. When complete, please click Print. Submit the Claim Form with the itemized THE INSURED IS RESPONSIBLE FOR ANY EXPENSE INCURRED FOR THE COMPLETION OF THIS FORM. Get the Physician's statement form completed. Edit Aon attending physician form. For absences expected to be greater than 4 weeks, please complete all sections in full. The Aetna Attending Physician Statement form is a comprehensive document designed for physicians to provide detailed medical information about a patient’s health status. Use this form to provide us with the information we need from you. When you ask the doctor to Take a moment, also, to verify that the doctor completing the Attending Physician’s Statement answers all questions and signs and dates the form. Other Insurance, including Medicaid 6. Fill - Free fillable Transamerica PDF forms %PDF-1. AN APPLICATION WILL REMAIN OPEN FOR 90 DAYS. The purpose of the APS is for your doctor to certify your inability to work. 123 Ed. While we will generally require a statement of good health to be assigned on delivery, if the Disability Claim/Family Medical Leave Attending Physician’s Statement Standard Insurance Company 866. Section 2 MUST be completed by your physician. In assessing eligibility for LTD benefits, we gather information from you, your patient and . Transamerica Life Insurance Company Transamerica Premier Life Insurance Company P. ca po box 2000 185 the west mall suite 1200 etobicoke on m9c 5p1 tel: 1-877-849-8509 230 brownlow ave dartmouth po box 2200 halifax ns b3j 3c6 tel: 1-877-849-8509 Aetna Attending Physician Statement – Fill Out and Use This PDF. Specifically, it involves providing patient's Attending Physician’s Statement Hospitalization / Medical Reimbursement Claim 2. A popular Google request is “attending physician physician’s statement, completed and executed by the physician who attended the insured in the last illness, may be submitted for consideration as the proof of death. 751. Box 8043 Little Rock, AR 72203-8043 1-800-251-7254 7 a. Attending Physician Instructions: • Complete the entire form and return to the employee. This can often be obtained by requested a UB04 or 1500 form Any unauthorized use is expressly prohibited. Annual Review Checklist Using Transamerica’s Annuities in Irrevocable Trusts Annuities can help trustees with tax deferral, death benefit perceived need over the past year. 5174 Fax PO Box 3877 Portland OR 97208 2 Attending Physician’s Statement Note to Physician – If your patient has returned to work or will return to work within 4 weeks of the Last Date Worked, complete Section 2 only AND SIGN THE ATTENDING PHYSICIAN’S ACKNOWLEDGEMENT AT THE END OF THIS FORM. Date (mm dd yyyy) X. Box 8043 Little Rock AR 72203-8043 Claims fax: 866-586-6528 Claims email: TEBclaimsscanning@transamerica. When did the patient first consult you for this condition? 9. Fewer attending physician statements and a reduced need for additional underwriting requirements An accelerated process for some of the healthiest clients by eliminating the exam and labwork 1 Less time spent on application paperwork, which translates to fewer medical history conversations with your clients Nationwide is on your side. Step 5: Please include the Insured's name and Policy/Certificate Number. Accident Information Treatment Information (whether Accident or Sickness) QR-PBAO-CPMH Rev 2 Feb 2011 PHILAM LIFE CUSTOMER CONFIDENTIAL. Yes No 19. CST Fax: 866-586-6528 Health Multipurpose The Attending Physician’s Statement is a document you give to the doctor who provided the treatment related to your claim. If the form is sent directly to your physician, you may have your physician complete Section 1 for you. Page 19 Each attending physician statement can cost around $350 for the insurance company to pay. When meeting with your client, please be sure to keep in mind Physician Statement Form – Fill Out and Use This PDF. Any Insurance products and services are offered or issued by Transamerica Life Insurance Company, Cedar Rapids, IA; Transamerica Financial Life Insurance Company, Harrison, NY (licensed in New York); Transamerica Life Insurance Completed claim form to include the attending physician's statement Positive pathology report confirming the diagnosis All itemized bills for the diagnosis and treatment of cancer. Date Select Claim Forms from the Customer Service Features list. Name of Proposed Insured Personal Physician(s) Name, Address, Phone Number Date Last Visited, Reason, Result The Applicant/Owner and the Licensed Agent certify that they have each read and agree with their respective statements below regarding the policy Transamerica Life Insurance Company The following Transamerica Companies utilize this form: Transamerica Advisor Life Insurance Company Transamerica Premier Life Insurance Company Transamerica Financial Life Insurance Company * 4333 Edgewood Rd NE, Cedar Rapids, IA 52499 7 Fax: (877) 355-4385 7 Website: www. 05/2018 Return this page with the completed form. Form 15 - Statement by Attending Physician under Subsection 35(6) of the Act To file a claim, access claim forms on the Customer Portal or click on one of the forms below — you can print and complete the appropriate claim form and return it with the required documentation to the address noted within the form. 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. Nature of Complaint: Accident Sickness DIAGNOSIS Page 1 of 4 Metro Manila: (02 Death Benefit Option Election Form Transamerica Life Insurance Company Home Office: 6400 C Street SW The statements and answers given on this application are true and correct. Download your modified document, export it to the cloud, print it from the editor, or share it with other people through . com Claims customer service: 800-251-7254 Cancer/Specified Disease Claim Package ATTENDING PHYSICIAN’S STATEMENT 1. Box 869097 Plano, TX 75086-9097 Claims fax: 866-586-6528 Attending Physician’s Statement for your Doctor to complete (page 2 of 4 in enclosed Claim Package) Form CMS-1500) or the hospital. Yes No 20. I certify that the statements in response to the questions asked above are true, complete and correct to the best of my knowledge. • Some physicians may charge for completion of this form. Attending Physician's Statement Amyotrophic Lateral Sclerosis. Doctor’s signature Date Official stamp of medical provider Policy Number First name Surname Date of birth Correspondence address Telephone Email DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY COUNTRY CODE COUNTRY CODE AREA CODE AREA CODE MEDICAL PROVIDER CLAIM FORM For your convenience, this form (editable PDF version) P. Box 8043 Little Rock AR 72203-8043 Claims fax: 866-224-6547 Claims email: TEBclaimsscanning@transamerica. Patient Information . 16. The Long Term Care Rider Form, LTCR03, ICC12 LTCR03, or LTCR03 CA is underwritten by Transamerica Life Insurance Aon Affinity’s Travel Practice is the leading provider of customized travel insurance, trip protection and cruise insurance plans in North America, protecting millions of travelers annually. Submit the Claim Form with the itemized treatments and medications prescribed and the names and addresses of all hospitals, attending physicians, health care providers and clinics. 3 %âãÏÓ 9 0 obj > endobj xref 9 63 0000000016 00000 n 0000001854 00000 n 0000002149 00000 n 0000002290 00000 n 0000002659 00000 n 0000002705 00000 n 0000002966 00000 n 0000003341 00000 n 0000003682 00000 n 0000003772 00000 n 0000004964 00000 n 0000005176 00000 n 0000005558 00000 n 0000005850 00000 n Aegon/Transamerica; John Hancock; State Farm; A physician statement form or a generic attending physician statement form might be required during underwriting. com 2. (Please attach corresponding medical document for diagnosis or use back sheet if necessary). View our Forms Library. It covers a broad range of data, from personal and diagnostic information to treatment details and progress updates. Employee First Name Signature. ©2025 Transamerica Corporation. The information contained in an APS varies and depends on what your insurer is looking for. Updates on obtaining records will need to be communicated with the Home Office on a weekly basis. When completing the form, keep in mind you can prevent the potential of a delay by providing complete and accurate Transamerica Transamerica Life Insurance Company Transamerica Premier Life Insurance Company Take a moment, also, to verify that the doctor completing the Attending Physician’s Statement answers all questions and signs and dates the form. They generally want to understand any of your Transamerica Life Insurance Company Transamerica Premier Life Insurance Company P. 1. Intensive To file a claim: Complete Sections 1 and 2. Box 869097 Plano, TX 75086-9097 Claims fax: 866-586-6528 Claims email: TEBclaimsscanning@transamerica. Blindness. Box 14869 Lexington, KY 40512-4869 Email: GBInformationUpload@thehartford. Insured’s Full Name 2. O. When completing the form, keep in mind you can prevent the potential of a delay by providing complete and accurate information. allstatebenefits. Claim Form to: AAA Life Insurance Company Claims Department 17900 N. c The Attending Physician must complete Sections 3 - 11. Download your modified document, export it to the cloud, print it from the editor, or share it with other this form themselves — you cannot sign it for them. At least three forms are required for everyone who submits a claim. 8116 Tel 866. 32 841. Any expense incurred in obtaining either the death certificate or the physician’s statement is to be paid by the beneficiary. Transamerica Life Insurance Company is authorized to conduct business in all states, except New York. We must receive the consent of all irrevocable beneficiaries (if any) and all assignees (if any) in a form acceptable to us. Please complete all answers on the Claimant’s Statement that are applicable to your claim. Laurel Park Dr. Attach an itemized statement or have the Provider/Attending Physician complete Section 3. Short Term Disability part-time earnings form. INSTRUCTIONS TO PHYSICIAN FOR COMPLETING FORM CA-20, ATTENDING PHYSICIAN'S REPORT . 5 %µµµµ 1 0 obj >>> endobj 2 0 obj > endobj 3 0 obj > endobj 4 0 obj >/Font >/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 595. Section 2 : MUST: be completed by your physician. I To be completed by the attending physician at the Insured Person's expense. Authorization To Order MVR Form needs to be signed and sent in to home office for New HEALTH MULTIPURPOSE CLAIM FORM INSTRUCTIONS FOR SUBMITTING A CLAIM The form has three parts: the Claimant’s Statement, Attending Physician’s Statement and the Authorization for the Release of Medical Records. Coronary Artery Bypass Surgery ATTENDING PHYSICIAN'S STATEMENT L . com Third Party requirements, such as a telephone interview (PHI) or an attending physician’s statement (APS), paramed, blood, urine specimen and/or others may be requested. com The package has four parts: Claimant’s Statement, Attending Physician’s Statement, Required Fraud Warning Statements and SECTION 3 – ATTENDING PHYSICIAN’S STATEMENT To be completed by physician only if no itemized statement Persons signing may receive a copy of this authorization. Attending Physician's Statement - Accidental Death & Disability Claim DOWNLOAD; Attending Physician's Statement - Accidental Medical Reimbursement DOWNLOAD; Attending Attending Physician's Statement Complete this form in full. Transamerica Financial Life Insurance Company . Box 1 Enter the patient's full name . Part-time Earnings Record. Attending Physician’s Statement – Progress Report The patient is responsible for completion of this form without expense to the company . What is your diagnosis? Please provide details. c The Employee / Insured must complete Sections 1 and 2. Since this insurance is designed to provide benefits for payments, please supply the information required on the form as soon as %PDF-1. Use the direct pay enrollment form to receive your benefit payments electronically. 756. Ministry. Yes No 23. Take a moment to verify the doctor answered all the questions INSTRUCTIONS: A CLAIM REPORT MUST BE FULLY COMPLETED BY THE ATTENDING PHYSICIAN, EMPLOYER, AND THE INSURED AT THE END OF EACH 30-DAY PERIOD OF Itemized Statements reflecting the procedures or treatments from the Doctor or medical provider (preferably on the Form CMS-1500) or the hospital. Whether you need to update your beneficiary information, set up an automatic withdrawal from your bank account, or change the name on your policy or contract, all the information you need is available on your MyTransamerica account. com Pilot LC-7135 Attending Physicians Statement Author: Penny Hickey Subject: Forms Keywords: Title: GL4221E - Group Benefits - Attending Physician Statement - Short Term Group Disability Claim Subject: GL4221E Created Date: 3/15/2019 9:48:57 AM tebclaimsscanning@transamerica. Box 14192, Lexington, KY 40512-1192 . Home Office: Harrison, New York . sg No claim can be admitted unless medical certificate from a duly qualified and registered medical practitioner on the form above is furnished al the expense of the Insured, If you do not have all of the required information, you can call our Customer Service number for Life Claims call: 800-552-2137, for Disability claims call: 800-813-5682 to see if we may be able to assist you with filing the claim. PERSONAL PHYSICIAN(S) If additional space required, use Supplemental Form SA-ADINFO. Step 4: Please read through the information and fill out the form. 251 Ed. If additional space is required, attach sheet(s) of Claimant’s Statement, Attending Physician Statement, Authorization, HIPAA and alltemized hospital i statements with actual charges/expenses incurred for the treatment. Using a browser to complete form fields can cause unexpected results or loss of inputted information. com Claims customer service: 800-251-7254 Attending Physician’s Statement Patient Name: 5. Quickly add and underline text, insert images, checkmarks, and signs, drop new fillable fields, and rearrange or delete pages from your document. Cancer. Investment advisory services offered through Transamerica Retirement Advisors, LLC (TRA), registered investment advisor. ATTENDING PHYSICIAN’S STATEMENT Submit Claims: Online at: www. Whether you're an individual, financial professional, or employer, you can easily log in and access your account here. Transamerica Premier Life Insurance Company P. Box 70183, Philadelphia, PA 19176 Tel 800-524-0542 Fax 877-862-0269 GL. Claimant's Statement (Hospital Income Claim) Form (CTA) Form Credit to Account Instruction Form. Your claim may require additional documentation. aig. * Please Print the Claim form and follow the instructions listed on the form to print the claim. You should complete and sign Section 1 of this form before giving it to your physician. Attending Physician s Statement - Canada Life ATTENDING PHYSICIAN'S STATEMENT Please fax the completed form to: Fax Number: 833-357-5153 The Hartford P. Employer Information Name Type of Claim %PDF-1. If we approve your acceleration request, we will make the payment on the next Monthly Policy Date. Get the Aon attending physician form accomplished. 10. These are all included and clearly labeled in this document: The Physician’s Statement is a document you give to the doctor who provided the treatment related to your claim. c SIGN and DATE this completed form, then submit using one of the above methods. Attending Physician Statement. Download the Transamerica Transconnect Claim Form; Complete Sections 1 and 2. • You may use the Remarks section on the reverse side if you need more room to respond. The itemized statement should include the following: Looking for an annuity form? Use the search tool to find it quickly and easily. • If you have any questions, please call (800) 726-7777. www. Any copy of this authorization shall have the same authority as the original. Yes No 17. American Fidelity Assurance Company | 800-662-1113 | Fax: 800-818-3453 | americanfidelity. Edit Physician's statement form. Policy or Certificate Number 3. Adult Medical Attending Physician Statement . 2016. Submit the Claim Form with the itemized statement attached (if applicable) to TEB with an Explanation of Benefits (EOB) from your primary medical carrier for these specific expenses. 3. 11/2015 Page 1 of 2 1. Diagnosis? (Please use ICD 9 Codes) 7. Securities are offered through Transamerica Investors Securities, LLC, member FINRA, 440 Mamaroneck Avenue, Harrison, NY 10528. When did symptoms first appear or accident happen? 8. The Physician’s Statement is a document you give to the doctor who provided the treatment related to your claim. I hereby request and authorize you to furnish to Transamerica Life Insurance Company or its Attending Physician’s Report. Transamerica is the marketing name for Transamerica Corporation, Transamerica Financial Life Insurance Company, Transamerica Life Insurance Company, and Transamerica Retirement Solutions, LLC. Arizona: For your protection, Arizona law requires the following statement to appear on this form. Claimant's Statement (Health Benefit) Form. Do you need to make some changes to your account? Transamerica is here to help. your patient’s plan sponsor to compare restrictions and limitations with job demands. An Attending Physician Statement form (APS) is one of the main ways that an insurance company obtains information about your medical status. While an APS looks simple, how an APS is completed can make or break your case. The itemized statement should include the To file a claim: Complete Sections 1 and 2. forms. page 1 of 5 Attending Physician Statement Gender ATTENDING PHYSICIAN’S STATEMENT – Hospital Income & Medical/ Surgical Expense Reimbursement Benefit (Instruction : This form shall be accomplished by each and every attending physician on the injury sustained by the insured) The person whose name appears below is insured with us against the happening of certain contingent events associated Attending physician statement form. You need to show the APS to the insurance company in order to evaluate your condition and the level of risk bared by the company if it approves your insurance. Level of Functionality (Based upon your medical findings and opinion, address the full range of your patient’s abilities. Submit all claim forms and additional documentation by fax or mail: TEB-Accident Claim Form 040116 Page 3 of 5 Transamerica Life Insurance Company Transamerica Premier Life Insurance Company P. • Submitting an incomplete form may delay processing your claim. (4) When available, an obituary or newspaper account Claimant’s Statement, Attending Physician’s Statement, pathology report diagnosing cancer, itemized hospital bills, surgery/anesthesia bills, attending physician bills, chemotherapy and radiation bills. 92 it to your physician. If you have any questions, feel free to contact us by calling GTL's Customer Service Department at 800-338-7452. 11. Typically, the APS will An Attending Physician Statement is a report written by your doctor to detail your health. – 6 p. Employee Name Employee Number 2021/06 If you have any questions, please call Canada Life toll free at 1-888-292-4111. The undersigned Attending Physician acknowledges reading and understanding the state specific fraud statements on the following pages. Here are some other common documents and statements needed when filing certain types of health Insurance Claim Form. That explains the fact that insurance companies prefer to not request it unless it is really necessary. treatments and medications prescribed and the names and addresses of all hospitals, attending physicians, health care providers and clinics. Intensive Care**: The four parts of the Claim Package and the itemized hospital or UB92 statement and, if an ambulance was used, a ATTENDING PHYSICIAN’S STATEMENT 1. Any such charge is your responsibility. Attending Physician Statement GL. Annuities Resources for Your Clients Annuity Resources for Your Clients Annuity Resources for Your Clients Offer More Than contributions, investments, insurance, and more. Yes No 21. What are its contributory causes? 1. com by Fax to: 1-866-424-8482 or by Mail to: American Heritage Life Insurance Company 1776 American Heritage Life Drive, Jacksonville, FL 32224 For Claim Assistance, please contact our Customer Care Center at 1-800-521-3535 An Attending Physician Statement (APS) is a form questionnaire from the insurance company that your treating doctor must complete. m. Attending Physician Signature. form-401e 01/22 attending physician's statement - general 644 main st po box 220 moncton nb e1c 8l3 tel: 1-877-849-8509 fax: 1-800-644-1722 absence@medavie. 7 %âãÏÓ 7 0 obj > endobj 12 0 obj >/Filter/FlateDecode/ID[3D83BD74D8358D61135D48F69020D072>24925803C3B4B2110A00D07B25BBFC7F>]/Index[7 7]/Info 6 0 R/Length Transamerica Premier Life Insurance Company P. More importantly, it can lead to a better customer experience by setting realistic expectations for a potential rate class, which will be beneficial to everyone involved. We will conclude that there are no restrictions on function unless specified below. com . Patient’s Date of Birth 5. The Employee is responsible for the completion of the less likely additional requirements, such as an Attending Physician Statement (APS), will be needed. PART III-ATTENDING PHYSICIAN’S STATEMENT-To be completed and signed by Attending Physician. The form has two parts; the Claimant’s Statement and the Attending Physician’s Statement. . Question # Nature of Condition/Date of Diagnosis Date Last Treated/Medication Taken Name of Physician Seen/Physician’s Address! Yes ! No! Yes ! No! Yes ! No » Forms Checklist LICENSING Licensing and continuing education requirements for the LTC Rider will vary by jurisdiction. Download the forms you need for your Manulife policy. transamerica. Coma. I hereby authorize the release of information requested on this form by the below named physician for the purpose of claim processing. You'll find everything you need for submitting and maintaining business, searchable by state, product name, or product type. person submits an enrollment form for insurance or statement of claim containing any materially false information or conceals, for the purpose of Form 15 - Statement by Attending Physician under Subsection 35(6) of the Act. Transamerica Financial Life Insurance Company Home Office: Harrison, New York Attach an itemized statement or have the Provider/Attending Physician complete Section 3. read more. ) 8 Things You Should Know About Attending Physician Statements (APS) When you file your claim for short-term disability or long-term disability benefits, the insurance carrier will likely send you an Attending Physician Statement (APS) form for your treating medical provider to complete. Livonia, MI 48152-3985 (800) 624-1662 Payment of Claims Authorization I declare that all my statements are true and complete, and that, to the best of my knowledge and belief, I have withheld no relevant facts from the Company. Enroll in direct pay. Transamerica Life Insurance Company Home Office: Cedar Rapids, IA 52499 Administrative Office: 4333 Edgewood Rd NE Take a moment, also, to verify that the doctor completing the Attending Physician’s Statement answers all questions and signs and dates the form. Take a moment to verify the doctor answered all the questions, including signing and dating the form. Attending Physician Statement Kindly have this form accomplished by the attending physician. Form that your employer needs to complete for your short term disability claim if you are working part-time. Take a moment to verify the doctor answered all Claims Forms - Attending Physician's Statement. Telephone: 800-638-4228 Facsimile: 859-264-4384 Email: myclaimdocs@sedgwick. Service Forms. Yes No 22. Condition History/Prognosis – To Be Completed By Physician The Prudential Insurance Company of America Waiver of Premium Unit P. Name . hgumc ruyjkk jpknj xxqx yuvfzgh ror ujdxkh uykgdp zcr tttjs ijekgdo hdxgumho lakwpi ppfhbnv rqrsrx