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24 Initial Attending Physicians Statement

24_Initial_Attending_Physicians_Statement

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35 views

24 Initial Attending Physicians Statement

24_Initial_Attending_Physicians_Statement

Uploaded by

bostrecovery
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Please fax the completed form to:

Fax Number: 833-357-5153


The Hartford
P.O. Box 14869 Attending Physician’s Statement – Initial
Lexington, KY 40512-4869 The patient is responsible for completion of this form without expense to the company
Email: [email protected]

Patient Last Name: Patient First (or Preferred) Name: Date of Birth: Claim Id Number:

Condition
Patient’s condition is a result of: If illness or injury, is condition related to: If pregnancy, what is date of delivery?
Illness Injury Work Activity _ _ /_ _ /_ _ _ _ Actual
MM DD YYYY
Pregnancy Motor Vehicle Accident Estimated
Intentional/Self-Inflicted

Condition onset: First day recommended Projected return to work Office visit to complete this form:
_ _ /_ _ /_ _ _ _ out of work: date: _ _ /_ _ /_ _ _ _ In Person
MM DD YYYY _ _ /_ _ /_ _ _ _ _ _ /_ _ /_ _ _ _ MM DD YYYY
Telemedicine
MM DD YYYY MM DD YYYY

Disabling Diagnosis(es) and Impact to Function


ICD 10 Codes Description of corresponding symptoms
Please provide most specific codes: __________________________________
|__||__||__|.|__||__||__||__| \ |__||__||__|.|__||__||__||__| __________________________________
Co-Morbid Conditions with Impact to Diagnosis
None Opioid Usage Psoriasis Mental Health
Diabetes Heart Disease Asthma/Bronchitis Cognitive Impairment
Hypertension Obesity Auto-Immune Disease In your opinion is the patient competent
COPD Arthritis Other ____________ to endorse checks and direct the use of
proceeds? Yes No
Treatment Plan
Conservative treatment Bed Rest Palliative care Hospice Care
Hospitalization Admittance date: _ _ /_ _ /_ _ _ _ Discharge date: _ _ /_ _ /_ _ _ _
MM DD YYYY MM DD YYYY

Next/Another appointment Date: _ _ /_ _ /_ _ _ _ In Person Telemedicine


MM DD YYYY

Physical/Occupational therapy |__| times per week until _ _ /_ _ /_ _ _ _ Actual Estimated


MM DD YYYY

Surgery Date: _ _ /_ _ /_ _ _ _ CPT Code(s): |__||__||__||__||__| \ |__||__||__||__||__|


MM DD YYYY

Referral to a specialist Type: _________________________ Contact Info:_________________________________


Current Medications (related to condition or impacting function)
None Over counter medications: ____________________________________________________________
Prescription medications Name(s): ____________________________________________________________
Impacting function? Yes No If yes, why? __________________________________________________
Chemotherapy Radiation Start Date: _ _ /_ _ /_ _ _ _ End Date: _ _ /_ _ /_ _ _ _
MM DD YYYY MM DD YYYY
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including underwriting companies Hartford Life and Accident Insurance
Company and Hartford Fire Insurance Company. Home Office is Hartford, CT. The Hartford is the administrator for certain group benefits business
written by Aetna Life Insurance Company and Talcott Resolution Life Insurance Company (formerly known as Hartford Life Insurance Company). The
Hartford also provides administrative and claim services for employer leave of absence programs and self-funded disability benefit plans.

LC-7135-13 Page 1 of 2 06/2021


Please fax the completed form to:
Fax Number: 833-357-5153
The Hartford
P.O. Box 14869 Attending Physician’s Statement – Initial
Lexington, KY 40512-4869 The patient is responsible for completion of this form without expense to the company
Email: [email protected]

Patient Last Name: Patient First (or Preferred) Name: Date of Birth: Claim Id Number:

Level of Functionality (Based upon your medical findings and opinion, address the full range of your patient’s abilities.
We will conclude that there are no restrictions on function unless specified below.)
Expected duration of any restriction(s) or limitation(s) listed below THROUGH _ _ /_ _ /_ _ _ _
MM DD YYYY
In a workday the patient is able to: (select either Continuous or Intermittent)

Continuously with Intermittently with If intermittent, enter time for each section below
standard breaks standard breaks
Hours at one time Total hours in a workday
Sit or |___| |___|
Stand or |___| |___|
Walk or |___| |___|

Key: C = Continuously (5.5 – 8 hours) F = Frequently (2.5 – 5.5 hours) O = Occasionally (up to 2.5 hours) N = Never

Activity Ability C F O N Activity Ability Right/Left C F O N


Drive Squat / Kneel
Weight bearing Hand Dominance R L
Climb
Fine Manipulation R L
Bend
Gross Manipulation R L
Max lift ____LBS ____LBS ____LBS ____LBS
Reach above shoulder R L
Max Carry ____LBS ____LBS ____LBS ____LBS
Reach below shoulder R L
Completed or Planned Diagnostic Tests, Labs and Imaging (related to the disabling diagnosis)
Completed: X-ray _ _ /_ _ /_ _ _ _ MRI _ _ /_ _ /_ _ _ _ CT _ _ /_ _ /_ _ _ _ EKG _ _ /_ _ /_ _ _ _
MM DD YYYY MM DD YYYY MM DD YYYY MM DD YYYY

ECHO _ _ /_ _ /_ _ _ _ EMG _ _ /_ _ /_ _ _ _ Lab Work _ _ /_ _ /_ _ _ _


MM DD YYYY MM DD YYYY MM DD YYYY

Findings of completed tests: No significant findings Confirmed diagnosis


Planned: X-ray MRI CT EKG ECHO EMG Lab Work Scheduled date _ _ /_ _ /_ _ _ _
MM DD YYYY

Provider Details
Provider Name: _____________________________ Email: _______________________
Specialty: _____________________________
Phone: ( _ _ _ ) _ _ _ - _ _ _ _
EIN Number: _____________________________
License Number: _____________________________ Fax: (___)___-____

Provider Signature: Date:


______________________________________________________________ _ _ /_ _ /_ _ _ _
MM DD YYYY

LC-7135-13 Page 2 of 2 06/2021

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