Attending Physician's Statement Form - The Hartford
This form is used to collect detailed information about a patient's medical condition, treatment, and ability to work. It needs to be completed by both the employee and the attending physician. This ensures the insurance company has all the necessary information to process claims properly.
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How do I fill this out?
Filling out this form requires both personal and medical information. Starting with the employee section, provide all required personal details such as name, DOB, and insured ID number. Ensure all medical sections are completed accurately by your attending physician.
How to fill out the Attending Physician's Statement Form - The Hartford?
1
Provide employee details including name, DOB, and insured ID number.
2
Physician fills out medical conditions details with current office visit information.
3
Include detailed ICD-9 or ICD-10 codes and relevant test results.
4
Specify treatment dates, medical conditions, and expected recovery dates.
5
Both employee and physician must sign and date the form.
Who needs the Attending Physician's Statement Form - The Hartford?
1
Employees seeking disability benefits due to medical conditions.
2
Physicians needing to document patient’s medical issues for insurance purposes.
3
Insurance companies requiring detailed patient information for claim processing.
4
Employers verifying employee’s inability to work due to health conditions.
5
Legal teams needing documented proof of medical conditions for proceedings.
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1
Open the PDF in PrintFriendly's PDF editor.
2
Use editing tools to fill out required fields and modify existing text.
3
Add ICD-9 and ICD-10 codes, test results, and medical conditions accurately.
4
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5
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What are the instructions for submitting this form?
Submit the completed form either by fax to 833-357-5153, mail to The Hartford, P.O. Box 14869, Lexington, KY 40512-4869, or email to GBInformationUpload@thehartford.com. Ensure all required fields are filled out and include any necessary medical documentation with the submission. Double-check all information for accuracy before sending.
What are the important dates for this form in 2024 and 2025?
Ensure timely submission to avoid delays in processing. Recommended submission dates are within 30 days post patient’s office visit.
What is the purpose of this form?
The Attending Physician's Statement Form is designed to collect comprehensive medical information about a patient's condition and treatment. This ensures an accurate assessment of eligibility for disability benefits. The form requires detailed input from both the patient (employee) and their attending physician, ensuring all medical and personal details are thoroughly documented for insurance processing.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name:: The full legal name of the patient.
- 2. Date of Birth:: The patient's date of birth.
- 3. Insured ID Number:: The personal identification number provided by the insurance.
- 4. Patient Address: The address where the patient resides.
- 5. Primary condition: The main medical condition affecting the patient.
- 6. Secondary condition(s): Any additional medical conditions impacting the patient.
- 7. ICD-9 Code: Specific code for diagnosis according to the International Classification of Diseases, 9th Revision.
- 8. ICD-10 Code(s): Specific code for diagnosis according to the International Classification of Diseases, 10th Revision.
- 9. Pertinent Test Results: List and attach relevant test results.
- 10. Treatments: Medical treatments prescribed to the patient.
- 11. Date you first treated this patient: The initial date when the patient was treated for the condition.
- 12. Date of reported onset of this condition: The date when the condition first became apparent.
- 13. Current Treatment Plan: Ongoing medical treatment described by the attending physician.
- 14. Date of most recent treatment: The most recent visit for treatment by the patient.
- 15. Provider's Signature: The attending physician's signature for validation.
What happens if I fail to submit this form?
Failure to submit this form can delay the processing of disability benefits or result in denial of claims.
- Delayed Benefits: Benefits may be delayed without proper form submission.
- Claim Denial: Incomplete or missing forms can lead to claim denial.
- Lack of Medical Documentation: Without the form, there is no official record of the patient's condition.
How do I know when to use this form?
- 1. Disability Claim: Submit when filing for disability benefits.
- 2. Medical Documentation: Use for documenting detailed medical conditions.
- 3. Legal Proceedings: Provide as evidence in legal health-related cases.
- 4. Workplace Accommodation: Submit for workplace accommodation requests based on health.
- 5. Insurance Verification: Provide to insurance companies for verifying health conditions.
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Yes, use the signature tool within the editor to add a digital signature.
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After completing the form, use the sharing tools for email or direct link options.
Can I attach test results within the form?
Yes, list all pertinent test results directly in the provided fields or attach them as separate documents.
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Follow the guided steps within the editor to ensure all mandatory fields are completed accurately.
What do I do if I make a mistake?
Use the editor's correction tools to modify any errors before saving.
Can multiple people fill out the form?
Yes, different sections can be filled by the employee and attending physician respectively.
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