Physician Statement for Medical or Surgical Expense Reimbursements

A. General Data of the Patient Name of the Patient: John Doe Date of Birth: 01/15/1980 Are you the patient’s regular physician?: Yes, I have been the primary provider for 5 years. How long has the patient been under your care?: 5 years B. Hospitalization/Consultation Details Name & Address of the Hospital /Clinic: St. Mary's Hospital, 123 Health St, London, UK Date of Admission/Consultation: 10/25/2024 Ward/Room No: 12B Date of Discharge: 10/30/2024 Chief Complaints / Concurrent Conditions: Severe abdominal pain and nausea. Laboratory / Diagnostic Procedures conducted: 10/26/2024 – Blood Test – Complete Blood Count – Elevated white blood cells. Treatment / Medications Given: Administered IV fluids and antibiotics. Diagnosis: Acute appendicitis. Cause of Hospitalization: Illness C. Related Conditions and Additional Factors Consultation/treatment on injury/ailment related to any of the following: None Are you the one who duly recommended and approved the hospitalization?: Yes Was surgical operation suggested?: Yes If Yes, please indicate below: Date: 10/27/2024 Type of Operation: Appendectomy Name & Address of Hospital: St. Mary's Hospital, 123 Health St, London, UK Was recovery uncomplicated and the period of hospitalization is normally expected for this type of case: Yes What is your prognosis?: Good, with full recovery expected. Do you know of any medical problem/s the patient had in the past?: Yes If yes, please provide details below: Date: 05/2019 Complaints/Symptoms: Frequent headaches Diagnosis: Migraine Treatment: Prescribed sumatriptan From - To: 05/2019 - 08/2019 Rehabilitation / Physical Therapy Details: Date: 11/01/2024 Hospital/Institution: St. Mary's Rehabilitation Center Type of Therapy: Post-operative physical therapy Duration: 5 sessions DECLARATION I hereby certify that the answers and information given above are full, complete and true. AUTHORIZATION I further authorize your Medical Director or any of his/her authorized representative or other person in your employ, to obtain or secure from me or any clinic, hospital or entity all the medical records of the above-named patient. A photographic copy of this authorization is valid as the original. Date: 11/01/2024 Signature Over Printed Name of the Attending Physician: Dr. Thomas Kelly License No: 123456 Address: 456 Medical Lane, London, UK