The Pearl Carroll Disability Claim Form stands as a crucial document for individuals intending to file for disability income benefits, necessitating detailed information about the claimant's medical condition, care providers, and return to work status if applicable. It requires a thorough account of one’s recovery or work resumption details, in addition to medical provider statements to support the claim. For those embarking on compiling their disability claim, completing this form with accuracy and mindfulness towards provided instructions is a pivotal step towards receiving the benefits you may be eligible for. If you're ready to proceed with your disability claim, ensure you fill out and submit the form by clicking the button below.
Navigating through the process of filing a disability claim can seem daunting, but understanding the structure and requirements of the Pearl Carroll Disability Claim form can significantly demystify this process. This comprehensive form facilitates individuals in submitting claims for disability income benefits, mandating meticulous documentation to ensure a smooth evaluation. It entails sections for personal information, detailing the nature and circumstances of the disability, employment details before the onset of the disability, along with a thorough list of medical providers that have been consulted. Critical to this procedure is the requirement for both the claimant and their medical provider to provide detailed statements about the disability and the medical care received. Additionally, the form entails provisions for updating the claims unit about any recovery or return to work, highlighting the need for ongoing communication between the claimant and Pearl Carroll & Associates. Instructions for the authorization for release of information are also included, emphasizing the importance of privacy and consent in the handling of personal medical records. Situated in Latham, NY, Pearl Carroll & Associates positions itself as a pivotal contact point for claimants, offering a structured yet flexible system for managing and communicating disability claims, underpinned by the necessity of accurate and complete submissions to expedite the claims process.
STATEMENT OF RECOVERY OR RETURN TO WORK
DISABILITY INCOME CLAIM INSTRUCTIONS
(PLEASE DETACH THIS NOTICE BEFORE MAILING AND KEEP FOR FUTURE REFERENCE)
Please answer all questions on the Member Statement on your Disability Income claim form
Please provide a complete List of Providers/Hospitals that treated you for this disability.
Date and sign both the Members Statement and the Authorization for Release of Information.
Please have your Medical Provider complete both pages of the Medical Provider’s Statement.
Please see that the completed form is returned to:
Pearl Carroll & Associates LLC
Disability Claims Unit
12 Cornell Road
Latham, NY 12110
If you recover or return to work, please notify Pearl Carroll & Associates immediately by completing and mailing this statement to the above address or emailing to Customercare@PearlCarroll.com.
If you have any questions concerning your request for Disability Income benefits, you may call the Office of the Administrator at 1-800-697-2732. The fax number is 518-640-8105. Please note that we will not confirm receipt of a fax for 24 - 48 hours.
Name: _______________________________________________________________________________
Mailing Address: _______________________________________________________________________
_______________________________________________________________________
Social Security No.: ______-______-________
Policy G-11628
I recovered:
I returned to work
Other (I.E. Returned to work light duty, another job etc):
Date:
Month/Day/Year
Date: _______________________ Signature: ___________________________________________
Email Address: __________________________________________________________________________________
CSEA DI ed 10/2016
CSEA MEMBER’S DISABILITY INCOME FORM
CLAIM TYPE:
Member Disability
Spouse-Coverage Disability
Non-Disabling Injury
Hospital Benefit
Survivor Benefit
Member Name:
____________________________________
Date of Birth: ___________________________
Social Security # _____________________________________
Male
Female
Spouse Name:
Social Security # ______________________________________
Mailing Address: _____________________________________________________________________
__________
(No.)
(Street)
(Apt No.)
_______________________________________________________________
(City or Town)
(State)
(Zip Code)
Telephone No.: Home: (
)______________________
Em ployer (
) ________________ Height: ________
Weight ________
Employer’s Name: ___________________________________________________________
Normal Number of Hours Worked Per Week: ________
Employer’s Street Address: ______________________________________________________________________________________
Email Address: ____________________________________________________________________________________________________
What is the nature of your disability?__________________________________________________________________________________
Is disability work related? Yes
No
If yes, please attach a copy of the Employee Accident Report signed by manager
Is disability due to an Injury? Yes
If “Yes”, when? _______/______/________
Mo .
Da y
Year
Where did it happen?__________________________________________________________
How did it happen? _______________________________________________________________
Date first treated for this disability:
_____/_____/_______
Mo.
Day
Date First Unable to Work: ______/______/______
Date Last Worked: ______/_______/_______
Have you attempted to return to your occupation since the date disability began? (If so, give details)
If returned to work or recovered, give date: _____/_____/______
Returned to work: Full Time:
Part Time:
If Part Time, # of hours per day _______
If not returned, when do you expect to? _____/_____/______
Are your working a second job? If so, please provide the name and address of the company and the hours you are working.
**If disability is due to a Motor Vehicle Accident, please attach MV-104A Police Report**
** If treated in hospital or Urgent Care Center, please attach a copy of your discharge papers**
1
Member’s Name ___________________________________ Member’s Social Security #________________________
Names and addresses of providers consulted and any other providers seen for treatment.
PLEASE PRINT – If you need more space, you may attach a sheet of paper with the additional names, addresses, and phone numbers. Be sure to include all providers, as any missing may delay your claim.
PHYSICIANS:
Name:
Address:
City:
State:
Zip:
Phone:
HOSPITALS
PHARMACIES
2
Member Name _______________________________________ Member’s Social Security #__________________________
Please state your occupation: ________________________________________________
**Please attach a copy of your official job description**
Please fully describe all the duties of your occupation at the time you stopped working including the percentage of time spent on
each activity:
_____________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
What are your daily activities?________________________________________________________________
_________________________________________________________________________________________________________
Are you receiving or will you be eligible to receive benefits from:
Workman’s Compensation?
Yes
Pension Plan?
Another Group Insurance Plan?
Individual Disability Income Policy?
Social Security Disability?
If “Yes” insert policy number, claim number and address of insurance company or organization providing such benefits and amount of payment.
Policy No.
Claim No.
Name and Address
Amount of Payment
I declare that the answers on Page 1, Page 2 and Page 3 of this form are complete and true to the best of my knowledge and belief. I also agree that I will advise the New York Life Insurance Company of my return to any type of work and that I will return any payments to which I am not entitled by reason of my return to work or termination of my disability.
New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Date: _____________
Member’s Signature _______________________________________________
MO/ DAY/YEAR
The Member or someone on his/her behalf must sign here and on the
Authorization for Release of Information Form.
Please see that the completed form is returned to:
12 Cornell Road – Disability Unit
Fax # 518-640-8105 or email to Customercare@PearlCarroll.com
3
Authorization for Release of Information
TO:
All providers of medical services and supplies, pharmacy related service organizations, prescription history database
suppliers, employers, insurance institutions, the Social Security Administration and other organizations.
I authorize release to New York Life Insurance Company or their representative, Pearl Carroll & Associates LLC, any independent claim administrators, consulting health professionals, pharmacy related service organizations and utilization review organizations with whom New York Life has contracted, information concerning health care advice, treatment or supplies provided the patient (including that related to mental illness and/or AIDS/ARC/HIV) and prescription records. This information will be used to evaluate claims for benefits.
In Oklahoma, the information authorized for release may include records which may indicate the presence of a communicable or non-communicable disease.
This authorization may be used for a period of 24 months from the date signed below unless sooner revoked. I may revoke this authorization at any time by notifying New York Life in writing at the address given on this form. My revocation will not be effective to the extent New York Life or any other person has already disclosed or collected information or taken other action in reliance on it. The information New York Life obtains through this authorization may become subject to further disclosure. For example, New York Life may be required to provide it to an insurance regulatory or other government agency. In this case, the information may no longer be protected by the rules governing this authorization.
A photocopy of this authorization and request form shall be as valid as the original. I know that I may request a copy of this authorization.
_____________________________________________
_________________________________
Patient’s Signature
Date
Print Name
Social Security No
______________________________________________
__________________________________
Address
City,
State
Zip
Email Address
Phone Number
Medical Records Release to: Datafied Inc. 1210 N. Jefferson St. Suite P Anaheim, CA 92807
4
MEDICAL PROVIDER’S STATEMENT
(The patient is responsible for the completion of this form without expense to the Company)
Notice to Provider: Thank you in advance for your cooperation in completing this form on behalf of your patient identified below. We will consider this information in conjunction with other information gathered to determine the claimant’s eligibility for benefits according to his or her specific contract with us. We will periodically request that you provide updated information, records and chart notes to enable our evaluation of a continuing claim. In order for us to expedite our consideration of your patient’s claim, please fully answer each question and sign and date the form where indicated.
1.PATIENT’S NAME: ______________________________________________ SOCIAL SECURITY NO.: __________________
(First)
(Middle)
(Last)
DATE OF BIRTH: _____/_____/______
2.
CURRENT MEDICAL CONDITION(s):
(Mo) (Day)
(Year)
PRIMARY DIAGNOSIS: __________________________________
ICD-10 CM CODE: _____________
SECONDARY DIAGNOSIS: _____________________________
3.
DATE THAT SYMPTOMS FIRST APPEARED OR ACCIDENT HAPPENED:
______/_____/_______
4.
DATE THAT PATIENT FIRST CONSULTED YOU FOR THIS CONDITION:
5.
DATE YOU LAST TREATED THE PATIENT:
6.
IS THIS CONDITION RELATED TO PATIENT’S EMPLOYMENT?
YES
NO
7.
WAS PATIENT REFERRED TO YOU BY ANOTHER PRACTITIONER?
(If “Yes”, please provide the name and address of that practitioner): __________________________________________________
______________________________________________________________________________________________________________
8.OBJECTIVE FINDINGS (Include x-rays, lab results and clinical findings. If pregnancy, also give LMP and EDC):
____________________________________________________________________________________________________
9. HAS PATIENT BEEN HOSPITALIZED? YES NO (If “YES”, provide reason, hospital name and dates of
confinement): ________________________________________________________________________________
10.NATURE OF TREATMENT CURRENTLY BEING PROVIDED OR PLANNED: (Include dates and type of surgery
and any medications prescribed if applicable): ___________________________________________________
_______________________________________________________________________________________
11.HAVE YOU REFERRED THE PATIENT TO ANOTHER PRACTITIONER? YES NO (If “Yes”, please provide the name and address of all applicable physicians or ): ________________________________________________________
12.IN YOUR OPINION IS THE PATIENT ABLE TO WORK AT THIS TIME? YES NO
IF “NO”, WHEN DO YOU EXPECT THAT THE PATIENT WILL BE ABLE TO PERFORM SOME WORK?
(Mo) (Day) (Year)
PATIENT’S NAME: ______________________________________________ SOCIAL SECURITY NO.: ____________________
13.IS THERE ANY TYPE OF JOB MODIFICATION OR ACCOMODATION THAT WOULD ENABLE THE PATIENT TO WORK
AT THIS TIME? YES NO (If “Yes”, please describe): _______________________________________
14.
BASED ON OBJECTIVE FINDINGS AND YOUR
MEDICAL OPINION:
a)
THE PATIENT WAS TOTALLY DISABLED FROM:
_____/_____/_____ THROUGH: _____/_____/_____
(Mo.) (Day) (Year)
b)
THE PATIENT WAS PARTIALLY DISABLED FROM:
15.LIST ALL CURRENT RESTRICTIONS AND LIMITATIONS YOU HAVE PLACED ON THE ATIENT’S WORK AND PERSONAL
ACTIVITIES DUE TO HIS OR HER MEDICAL CONDITION (If none, indicate “NONE): ___________________________________
16. HAS THE PATIENT BEEN RELEASED FROM YOUR CARE? YES
IF “YES” DATE RELEASED FROM YOUR CARE:
IF “NO”, DATE OF NEXT SCHEDULED TREATMENT OR EVALUATION:
______/_______/________
______/_______/_________
MEDICAL PROVIDER’S DECLARATION AND SIGNATURE
I declare that the answers on this statement are complete and true to the best of my knowledge and belief. I understand that periodic updates (including providing copies of medical records when requested) will be required in the event of a continuing claim.
_______________________________________ _____
__________________
_______________________
PROVIDER’S NAME (PLEASE PRINT)
Specialty
TELEPHONE NUMBER
_________________________________________________
___________________________________________________
STREET ADDRESS
CITY
STATE
ZIP CODE
PROVIDER’S SIGNATURE
DATE SIGNED
Please return completed forms to:
Fax # 518-640-8105 or email to CustomerCare@PearlCarroll.com
Filing a disability claim can often seem like a daunting process, but with clear guidance, it can be made simpler. The goal in completing the Pearl Carroll Disability Claim form is to ensure that all your information is accurate and comprehensive, to avoid any potential delays in the processing of your claim. By following the steps outlined below, you will be prepared to submit your claim accurately and efficiently.
Once your form is submitted, please allow some processing time. You may contact Pearl Carroll & Associates through the phone number provided if you have any questions regarding your claim or its status. Remember, keeping a copy of all documents submitted for your records is always a good practice.
How do I fill out the Pearl Carroll Disability Claim Form?
To properly fill out the Pearl Carroll Disability Claim Form, ensure you complete every section thoroughly. Begin with the Member Statement on your Disability Income claim form, providing detailed responses to all questions. You must also include a comprehensive list of all providers or hospitals that treated you for your disability. Both the Member's Statement and the Authorization for Release of Information need to be dated and signed by you. Additionally, request your Medical Provider fill out the designated sections on the Medical Provider’s Statement. Finally, make sure to return the fully completed form to Pearl Carroll & Associates LLC, 12 Cornell Road, Latham, NY 12110, by mail or emailing it to Customercare@PearlCarroll.com.
What should I do if I recover or return to work after submitting my Pearl Carroll Disability Claim?
If you recover or return to work, it's crucial to promptly notify Pearl Carroll & Associates by completing the Statement of Recovery or Return to Work section of the claim form. This information should be sent as soon as possible to the same address you submitted your claim to, or via email to Customercare@PearlCarroll.com. This step ensures your file is updated accurately and helps prevent any potential overpayments.
Who should I contact if I have questions about my Disability Income Benefits request?
If you have any questions regarding your request for Disability Income benefits, do not hesitate to contact the Office of the Administrator. You can reach them by calling 1-800-697-2732. They are available to assist with any inquiries you may have about the process, your claim status, or specific details related to your benefits.
What happens if I need to submit additional documents or information for my claim?
Should there be a need to submit additional documents or information after you've already sent your claim, you can mail these to Pearl Carroll & Associates LLC, 12 Cornell Road, Latham, NY 12110. Additionally, documents can be faxed to 518-640-8105. However, please note that the receipt of faxes will not be confirmed until 24 - 48 hours after submission. If you're submitting sensitive or extensive updates, consider using a method that provides a delivery confirmation for your records.
Can I revoke the Authorization for Release of Information after it's been submitted, and how?
Yes, you are permitted to revoke the Authorization for Release of Information at any point after it has been submitted. To do so, you must notify New York Life in writing to the address provided on the form. It's important to remember that revoking your authorization will not affect any actions already taken based on the consent given prior to the revocation. This means that any information shared or collected before the revocation cannot be undone. Writing a clear and dated letter stating your wish to revoke the authorization is the best approach to complete this process.
Filling out the Pearl Carroll Disability Claim form accurately is critical to ensuring a smooth claims process. Unfortunately, several common mistakes can delay or affect the claim. One major mistake is not answering all the questions on the Member Statement of the Disability Income claim form. Incomplete answers can cause unnecessary delays as the company may need to request additional information.
Another common error is providing an incomplete list of providers/hospitals that treated the disability. This list is crucial for a thorough evaluation of the claim, and missing information could lead to a denial or request for further documentation, slowing down the process.
Individuals often forget to date and sign both the Member's Statement and the Authorization for Release of Information. These signatures are legally required for the claim to be processed, and their absence can invalidate the submission.
Similarly, not having the Medical Provider complete both pages of their Statement is a critical oversight. The medical provider’s insights are essential for assessing the disability claim, and incomplete information can lead to misinterpretation of the condition or the needs of the claimant.
Failure to notify Pearl Carroll & Associates immediately upon recovery or return to work is another significant error. Timely communication about any change in work status is crucial for the adjustment of benefits and avoiding overpayments, which could lead to complications or the need for repayment.
On the technical side, not confirming receipt of a faxed submission within 24-48 hours can lead to uncertainty about whether the necessary documents have been received and are being processed. This can create anxiety and delay in getting the confirmation of the claim submission's status.
Forgetting to include mandatory attachments like the MV-104A Police Report for accidents or discharge papers for hospital stays can also be problematic. These documents provide essential details for validating the claim, and their absence can halt the processing of the claim.
One often overlooked detail is not attaching a copy of the official job description. This information helps assess the claimant's inability to perform their job duties, which is a key factor in determining eligibility for disability benefits.
Lastly, providing incomplete or inaccurate information regarding other sources of income or benefits can jeopardize the claim. Benefits from Workman’s Compensation, other disability insurance, or Social Security Disability must be disclosed, as they can affect the claim’s approval and the benefit amount.
When navigating the complexities of filing a disability claim, it's essential to understand that the Pearl Carroll Disability Claim form is just the starting point. Complementing this form with additional documents not only strengthens your claim but also ensures a smoother process. These documents serve as pillars, providing detailed evidence and insight into your situation, ultimately facilitating the assessment and approval of your claim.
Collecting and submitting these documents alongside your Pearl Carroll Disability Claim form can significantly influence the outcome of your claim. Not only do they provide a detailed representation of your case, but they also ensure that the review process can be conducted efficiently and effectively. Remember, thorough documentation can be the key to a successful disability claim.
The Pearl Carroll Disability Claim form mirrors the structure and content of a Workers' Compensation Claim Form. Both forms are designed to gather detailed information about an individual's employment, nature of their disability or injury, and whether the condition is work-related. Additionally, they require a list of medical providers, hospitals visited, and treatments received, showcasing their parallel in collecting comprehensive data to assess claims efficiently.
Similar to a Health Insurance Claim Form, the Pearl Carroll document collects personal information, health condition descriptions, and medical provider data. Both types of forms are used to claim benefits and require the patient’s and healthcare provider's signatures to authorize the release of medical information, ensuring the insurance company can verify the claim's validity and proceed with benefit disbursement.
The document also shares similarities with a Social Security Disability Benefits Application. Both require detailed descriptions of the disability, information on the ability to work, and disclosure of any other benefits the applicant might be receiving. These similarities are essential to establish the disability's impact on the applicant's daily life and work, key elements in both application processes.
Similarities can be drawn to an Auto Insurance Claim Form when it comes to accidents, specifically if the disability results from a motor vehicle accident. Both forms ask for details about the accident, including the date, location, and how it occurred. Importantly, they might request a police report or other documentation to substantiate the claim related to the accident.
The form closely aligns with the structure of a Life Insurance Beneficiary Claim Form, particularly in how it handles policy numbers and claimant information. While the Pearl Carroll form focuses on disability, both forms aim to provide financial support in response to life-changing events, requiring detailed documentation and verification to process claims.
It bears resemblance to a Long-Term Care Insurance Claim Form, as both inquire about the claimant’s medical condition, care requirements, and healthcare providers' information. The emphasis on detailed medical history and the need for thorough documentation reflects their shared goal of providing ongoing support for individuals facing long-term health challenges.
Similar to a Veteran’s Affairs (VA) Disability Claim form, the Pearl Carroll document collects extensive information on the nature of the disability, its impact on the individual's work capacity, and any military service-related injuries. Both are critical in determining the extent of benefits the claimant is entitled to, underscoring the importance of detailed and accurate information.
The format and purpose of the Pearl Carroll form align with an Unemployment Insurance Claim Form, especially in sections that ask about the claimant's last day of work and expected return to work date. Both forms are crucial for individuals who have lost income due to disability or unemployment, focusing on verifying eligibility for benefits meant to replace lost wages.
Similarly, the Pearl Carroll form shares characteristics with a General Liability Insurance Claim Form, especially in incidents where an injury might have occurred on someone else's property or due to someone's negligence. Like liability claims, the disability form asks for specifics about how the injury occurred, aiding in the determination of liability and benefits allocation.
Lastly, the document parallels a Family Medical Leave Act (FMLA) Request Form in sections that detail the medical condition and expected duration of absence from work. Both are essential for individuals needing time away from work due to medical conditions, emphasizing the need for sufficient documentation to support the request for leave or benefits.
Filling out the Pearl Carroll Disability Claim Form is a crucial process that necessitates attention to detail and accuracy to ensure that your claim is processed efficiently. Below are guidelines on what to do and what not to do during this process:
There are several common misconceptions regarding the Pearl Carroll Disability Claim form process. Addressing these misunderstandings can help individuals navigate their claims more effectively.
Misconception 1: You only need to notify Pearl Carroll & Associates of your recovery or return to work if you're resuming your job at full capacity. Clarification: Any change in your employment status, including part-time work or light duties, requires notification.
Misconception 2: The claim form is the only document required for your disability claim. Clarification: A complete list of all medical providers who have treated you for your disability and any relevant reports, such as a police report for a motor vehicle accident or your official job description, are also necessary.
Misconception 3: The completion of the Member's Statement is sufficient for processing your claim. Clarification: Both the Member's Statement and the Medical Provider’s Statement must be fully completed and submitted.
Misconception 4: Once submitted, Pearl Carroll will immediately confirm receipt of your fax. Clarification: Confirmation of a fax receipt might take 24-48 hours.
Misconception 5: Email is not an acceptable way to submit your statement of recovery or return to work. Clarification: You can notify Pearl Carroll & Associates of your change in work status via email or by mailing the statement.
Misconception 6: Disability due to work-related injuries is not covered. Clarification: You are asked to indicate whether the disability is work-related and attach an Employee Accident Report if applicable, suggesting coverage possibilities for such conditions.
Misconception 7: You cannot file a claim for a non-disabling injury. Clarification: The form includes non-disabling injuries as a claim type, allowing for such claims under certain conditions.
Misconception 8: Social Security Numbers aren't crucial for the claim process. Clarification: The form requests Social Security Numbers in several sections, underscoring their importance in identifying your policy and processing claims.
Misconception 9: If you've returned to work or recovered, your claim process is complete. Clarification: Notifying Pearl Carroll & Associates of your return to work or recovery is a critical step in the claim process, and you must also return any payments to which you are no longer entitled.
Understanding these misconceptions and their clarifications helps ensure that individuals can complete the Pearl Carroll Disability Claim form accurately and efficiently, which facilitates the processing of their claims.
Filling out the Pearl Carroll Disability Claim form properly is crucial for your claim's success. Here are five key takeaways to ensure you complete it correctly and utilize it effectively:
Remember, the accuracy and completeness of the information you provide on the Pearl Carroll Disability Claim form not only affect the speed at which your claim is processed but also its approval. Don't rush through filling it out, and double-check everything before submission.
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