Free Physician Statement Form in PDF

Instructions on Writing Physician Statement

Filling out the Physician Statement form is a crucial step in providing necessary information for insurance purposes. This document needs to be completed accurately to ensure there are no delays. It involves both the primary insured's details and extensive information from the examining physician regarding the patient's medical condition and diagnosis. Following the steps below will guide you through the process of completing this form correctly.

1. Start by entering the Primary Insured’s Name, Policy Number, and Insurance Purchase Date in the designated fields at the top of the form.
2. Under PATIENT INFORMATION, fill in the patient's name, date of birth, street address, city, state, and zip code.
3. In the Examining Physician Information section, enter the physician’s name, specialty, street address, city, state, zip code, phone number, and fax number.
4. Indicate if you are the patient's primary care physician by selecting Yes or No. If No, provide the name and phone number of the primary care physician.
5. Mark whether the patient was referred to you by their primary care physician with a Yes or No.
6. Under Patient’s Diagnosis, confirm if an actual examination was performed with a Yes or No and input the date of the exam.
7. Indicate the primary diagnosis for which the patient was examined, including the ICD-9 Code and date symptoms first appeared or accident occurred.
8. If the condition is a complication of an underlying condition, select Yes and specify; otherwise, select No.
9. List the dates of the patient's office visits in the 120 days before the insurance purchase date and circle the dates where the patient was treated for the stated condition.
10. Specify if you advised the trip be cancelled or interrupted due to the patient’s medical condition with a Yes or No, and provide the date.
11. Provide details on why you made or did not make the recommendation to cancel or interrupt the trip, including relevant circumstances and medical diagnosis.
12. If the patient is the insured, record the date when he/she became medically unable to travel.
13. Finally, the physician must sign and stamp the form at the bottom, including the date.

Upon completing the form, it should be sent via the method requested by the policy, such as email, mail, phone, or fax. Detailed information on these options is provided at the bottom of the form. It's important to reach out to the specified contact if there are any questions or further details needed to ensure timely processing and support.

What is a Physician Statement Form?

A Physician Statement Form is a document completed by a doctor (the examining physician) that provides key medical information about a patient. This information often pertains to insurance claims, particularly in the context of travel insurance or health insurance. The form records the patient's diagnosis, treatment dates, and the doctor's recommendation about whether or not the patient should travel, among other details.

Who needs to fill out the Physician Statement Form?

This form must be filled out by two parties: the primary insured or the patient provides their personal and insurance details, and then the examining physician fills out the rest, which includes detailed medical information about the patient's condition, treatment, and advice regarding travel or claim relevant activities.

What information is required from the patient?

The patient needs to provide their name, insurance policy number, and the date of insurance purchase. This initial information helps link the form to the correct insurance policy.

What is the role of the examining physician in completing the form?

The examining physician needs to provide detailed medical information, including the patient's diagnosis, the dates of office visits before the insurance was purchased, and whether the medical condition was a factor in any trip cancellation or interruption. They must also indicate if they are the patient’s primary care physician or if they were referred by one.

Is it necessary for the physician to be the patient’s primary care doctor?

No, it is not necessary. However, the form does ask whether the examining physician is the patient’s primary care doctor and, if not, who is. If the patient was referred by their primary care physician, this should be noted as well.

What if the patient was referred to the physician by another doctor?

There is a section on the form to indicate whether the patient was referred by their primary care physician. This information helps clarify the chain of medical consultation and the context of the examination.

What happens if the physician did not actually perform an examination?

The physician is asked to confirm whether they performed an actual examination of the patient. If no examination was performed, it may affect the validity of the provided information and could influence the insurance claim's outcome. Actual examination details are crucial for most insurance claims.

How does the form affect insurance claims?

The information provided on the form is used by insurance companies to make decisions about claims, especially in cases of travel insurance where trip cancellations or interruptions due to medical reasons are involved. Accurate and detailed medical information supports the patient's case for insurance compensation.

Can a physician refuse to fill out this form?

While physicians are generally cooperative in filling out necessary paperwork for their patients, there may be instances where a physician might refuse due to policy, privacy concerns, or other reasons. It's essential for patients to communicate clearly with their doctors about the need for this documentation and to seek assistance promptly if challenges arise.

What steps should be taken after the form is completed?

Once the form is filled out, it should be sent to the appropriate insurance provider, as indicated on the form. The contact details including email, mailing address, and fax number are provided. For a swift claims process, it's important to ensure the form is completely and accurately filled out and submitted promptly.

One common mistake made by individuals while filling out the Physician Statement form is neglecting to provide complete information in the patient information section. This section requires the patient's full name, date of birth, address, and other personal details. Omitting any part of this information can lead to the form being considered incomplete, delaying the processing of the form or even its outright rejection. Accurate and comprehensive details ensure a smoother claims process.

Another error often encountered is in the documentation of the patient’s diagnosis and examination details. Physicians are asked to indicate whether they performed an actual examination, provide the primary diagnosis, and mention any underlying conditions. However, sometimes, the information provided is either too vague or the section is left partially filled. This lack of detail can cause significant delays, as the insurance company may require further clarification or additional documentation to proceed with the claim.

The section concerning the history of the patient’s office visits in the 120 days before the insurance purchase is also frequently filled out incorrectly. Specifically, failure to accurately circle the dates when the patient was treated for the condition mentioned can create confusion. This information is crucial for the insurance company to determine the pre-existing nature of a condition, which can significantly impact the outcome of a claim. It's important to record this information with precision to support the claim's validity.

Lastly, a critical oversight often made is not providing a clear recommendation regarding the necessity to cancel or interrupt the trip due to the patient's medical condition. In cases where the physician advises against traveling, it is essential to offer a detailed explanation to support this recommendation. The absence of this explanation or providing a vague justification may hinder the insurance company's ability to assess the claim correctly. Clear, detailed medical reasoning helps to substantiate the claim and facilitates a smoother review and approval process.

When managing healthcare documentation, particularly in contexts requiring detailed medical information such as insurance claims or health support services, the Physician Statement Form is frequently complemented by additional forms and documents. These additional documents provide a comprehensive view of the patient's medical history, treatment plans, and overall health status, enabling more informed decision-making by involved parties. Below is a list of other crucial forms and documents often used alongside the Physician Statement Form.

• Medical Records Release Form: This form authorizes the transfer of a patient's medical records from one healthcare provider to another. It ensures confidentiality and compliance with healthcare privacy laws.
• Health Insurance Claim Form: Used by patients or healthcare providers to file for insurance coverage of medical services received. It contains detailed information on the services provided, their cost, and the insurance information.
• Medication List: A comprehensive record of all medications a patient is currently taking, including dosages and frequency. This document is crucial for reviewing potential drug interactions and understanding the patient's treatment regimen.
• Treatment Plan: Outlines the proposed approach for managing a patient's condition, including diagnostics, treatments, procedures, and follow-up care. It is developed by the healthcare provider to document the course of action for the patient's care.
• Advance Directive: A legal document that outlines a patient's preferences for medical treatment in situations where they are unable to make decisions for themselves. This can include a living will and designation of a healthcare proxy.
• Disability Certification Form: Used to certify a patient's disability status. This document provides official documentation of the patient's condition that qualifies them for disability benefits or accommodations.

Together, these documents form a detailed record of a patient's medical history, preferences, and treatment, playing a critical role in various administrative and legal processes. They ensure that healthcare providers, insurance companies, and other relevant entities have access to the necessary information to make informed decisions regarding the patient's care and support needs.

The Disability Verification Form closely resembles the Physician Statement Form. Both require detailed information from a healthcare professional regarding the patient's condition and its impact on their ability to perform certain activities, such as work in the case of the Disability Verification Form, or travel, as with the Physician Statement Form. They share a common goal: to provide an authoritative assessment from a healthcare provider that supports an application process – be it for insurance claims, disability benefits, or similar.

Medical Records Release Form has similarities to the Physician Statement Form, particularly in the way it handles patient information. While the Physician Statement Form requires a doctor to detail a patient's medical condition and ability to travel, the Medical Records Release Form is used to authorize the sharing of a patient's medical history between healthcare providers or with other authorized parties. Both involve strict protocols for handling personal health information and serve as critical documents in managing a patient's care and associated administrative processes.

The Patient History Form is another document that shares features with the Physician Statement Form. It collects comprehensive health information directly from the patient, such as medical history, allergies, and current medications, which is somewhat mirrored in the Physician Statement Form's requirement for the doctor to detail the patient’s medical condition and treatment. The critical similarity lies in their role in informing healthcare decisions – one from the patient’s perspective and the other from a clinician’s assessment.

The Prior Authorization Form for prescription drugs is akin to the Physician Statement Form in its function within the healthcare and insurance ecosystem. This form is completed by a physician to justify the medical necessity of a specific medication for a patient's condition, similar to how a Physician Statement Form might be used to substantiate a claim related to travel insurance based on medical grounds. Both forms require detailed medical justification to support the requestor's case to an insurer or another third party.

The Worker’s Compensation Claim Form shares the objective of documenting an individual's medical condition and its implications, akin to the Physician Statement Form, but does so within the context of workplace injuries or illnesses. It necessitates detailed physician input regarding the nature of the injury or illness, treatment plans, and the employee's capacity for work. Both documents are pivotal in determining the eligibility for benefits or claims based on health-related incidents.

The Health Insurance Claim Form is a critical document used by healthcare providers to claim payment from health insurance companies for services rendered. It parallels the Physician Statement Form in its necessity for detailed patient and service information but is broader in its application across various healthcare services. Both forms are instrumental in the process of claiming health-related benefits, though they serve different stakeholders within the healthcare and insurance sectors.

When filling out a Physician Statement form, it's essential to provide accurate and clear information. The following lists will help guide you through what you should and shouldn't do to ensure the process is completed effectively.

Things You Should Do

1. Ensure all patient information is filled out completely and accurately, including name, date of birth, address, and any other required details.
2. Verify that the examining physician's information is correct, including their name, specialty, address, phone number, and fax number.
3. Answer all questions truthfully, particularly those concerning the patient's diagnosis, treatment, and any advice given regarding travel restrictions due to medical conditions.
4. Include the primary diagnosis with the appropriate ICD-9 Code, and detail the date symptoms first appeared or the date of the accident.
5. Have the examining physician sign and date the form, ensuring their stamp is also affixed, if applicable.

Things You Shouldn't Do

• Do not leave sections incomplete. If a question is not applicable, mark it as "N/A" instead of leaving it blank.
• Do not provide false or misleading information. This includes exaggerating the patient's condition or symptoms.
• Avoid using medical jargon or abbreviations that may not be understood by the insurer. Instead, provide clear and concise descriptions.
• Do not forget to list all dates of the patient’s office visits within the 120 days before the insurance purchase date, especially those pertinent to the stated condition.
• Do not delay in sending the completed form to the insurer. Prompt submission can help avoid delays in the claims process.

By following these guidelines, you can help ensure that the Physician Statement form is filled out correctly and efficiently, facilitating a smoother claims process.

Understanding the Physician Statement form can be crucial in effectively managing insurance claims related to health issues, especially when it comes to travel insurance. However, several misconceptions exist about this form which can lead to unnecessary complications or delays. It's important to clarify these misunderstandings:

1. All physicians can complete the form. Only the examining physician who has treated or diagnosed the patient should complete the form to ensure the information is accurate and based on a professional assessment.

2. Any medical information is relevant. The form specifically requires information related to the condition that could affect the insured’s ability to travel. Not all medical history may be relevant to this evaluation.

3. Electronic submissions are less valid. Whether submitted by mail, fax, or email, all forms are treated with the same level of validity. The key is to ensure that the form is complete and the physician's signature is included.

4. The form only benefits the insurance company. While it's true that the form serves to inform the insurance company, it also protects the insured by providing a professional medical opinion that supports their claim.

5. A signature is enough for the form’s submission. Alongside the signature, the physician's stamp (if available) is also crucial as it adds to the authenticity of the form.

6. The physician’s personal opinion on the patient’s condition is sufficient. The form requires a clinical assessment based on an examination, diagnosis, and medical records, not just a personal opinion.

7. ICD-9 codes are outdated. While most practices have shifted to ICD-10, the mention of ICD-9 exemplifies the necessity of using standardized diagnostic codes, and one should ensure the use of current codes when completing the form.

8. The form is only for severe illnesses. The physician statement form should detail any condition that affects the insured’s ability to travel, not just severe illnesses. It's about the impact on travel ability, not illness severity.

9. Only the diagnosis is important. While the diagnosis is crucial, the form also requests information about the onset of symptoms, the relationship of the condition to any underlying issues, and the physician's recommendation regarding travel, which are all essential for a complete understanding of the patient's situation.

Correcting these misconceptions facilitates a smoother process for all parties involved. It ensures insurance claims related to health issues and travel are handled efficiently, with clarity and evidence-based assessments leading the way.

Filling out and using the Physician Statement form is a critical process for ensuring that insurance claims related to medical conditions are accurately processed. Here are five key takeaways to guide you through this process.

• The form must be completed by both the primary insured individual and the examining physician, ensuring that details such as policy number, patient information, and physician details are accurately filled in.
• It's important for the examining physician to clearly document the patient's diagnosis, including primary diagnosis and any complications of underlying conditions, with precise dates for when symptoms appeared or when an accident occurred. This information is crucial for the insurance provider to understand the nature and timing of the medical condition in question.
• The form requires information on whether the patient was advised to cancel or interrupt their trip due to the medical condition. The physician's recommendation and the reasons behind it provide critical context for the insurance provider when assessing the claim.
• Physicians need to list the dates of the patient’s office visits in the 120 days before the insurance purchase date, highlighting the visits related to the condition. This helps the insurance provider determine if the condition was pre-existing and its severity before the policy was purchased.
• The examining physician must certify the form with their signature and stamp, making it a legal document. The completed form can be submitted through various channels provided, including email, mail, fax, or phone call, ensuring that the claim is processed promptly.

Correctly filling out the Physician Statement form is vital for the successful processing of insurance claims related to medical conditions, requiring careful attention to detail and accurate documentation from both the insured and the examining physician.