Generic Attending Physician Statement for Insurance Claims

PATIENT’S INFORMATION Name: [insert full legal name of patient] (Enter the complete name of the patient in Last Name, First Name, Middle Name format; include only if stated) Date of Birth: [insert patient’s date of birth] (Write in mm/dd/yyyy format; include only if explicitly mentioned) Gender: [insert gender of patient] (State as either Male or Female; only include if mentioned) 1. Name the Critical Illness/Dismemberment the patient is experiencing: [insert diagnosis] (State the name of the confirmed diagnosis or dismemberment; refer to eligible conditions listed in the policy if specified) a. Date of first consultation: [insert date of first consultation] (Use mm/dd/yyyy format; only include if explicitly mentioned) b. Duration of illness since first consultation: [insert number of months] (State as number of months or timeframe; only include if provided) c. Full and exact details of diagnosis: [insert diagnosis detail] (Write a paragraph in full sentences describing the nature, classification, or staging of the illness. Attach references if instructed) d. Contributory causes: [insert contributory causes] (Write a short paragraph or list of underlying conditions or risk factors contributing to the main illness; only include if documented) 2. Objective findings supporting the diagnosis and prognosis: [insert test findings] (Include all relevant tests such as histopathology, ECG, MRI, etc. Format as: date, type of test, result. Use line or paragraph format depending on how information is given) a. Date of test: [insert date] (Use mm/dd/yyyy format) b. Type of test: [insert name of test] 3. Is the patient capable of performing activities of daily living?: [insert yes or no] (State clearly yes or no; include only if specifically asked or documented) If no, please state relevant period: From: [insert start date] Until: [insert end date] Details: [insert details of activities patient cannot perform] (Write in sentence or short paragraph form; include only if mentioned) 4. Has the patient been hospitalized or attended to for any other medical condition?: [insert yes or no] (Only include if stated. If yes, complete table below) a. What activities can the patient not perform?: [insert specific ADLs] (Provide a sentence listing the activities, such as bathing, walking, dressing, etc.) Name of Doctor/Hospital: [insert full name and institution] Complete Address: [insert address] Dates Attended: [insert date range] Disease or Condition: [insert condition] 5. Are you the patient's regular attending physician?: [insert yes or no] (Include short explanation of relationship or treatment history only if yes) Details on patient’s past health history: Date: [insert relevant dates] Complaints/Symptoms: [insert presenting issues] Diagnosis: [insert diagnosis] Treatment: [insert treatments given] From - To: [insert duration] 6. Is the patient's condition a mental or nervous disorder?: [insert yes or no] (Include only if applicable and stated) 7. Is the treatment related to pregnancy, miscarriage, abortion or childbirth?: [insert yes or no] 8. Is the condition sustained from being intoxicated or under the influence of drugs?: [insert yes or no] 9. Is the condition sustained from alcoholism or drug addiction?: [insert yes or no] 10. Is the treatment for routine physical check-up, rest cure, or special nursing care?: [insert yes or no] 11. Is the patient's condition congenital?: [insert yes or no] 12. Is the treatment for cosmetic reasons, a dental treatment or an elective surgery?: [insert yes or no] 13. Is the treatment for circumcision, sterilization, artificial insemination, sex transformation, or treatment of infertility?: [insert yes or no] 14. Is the patient's condition AIDS-related or due to a sexually transmitted disease?: [insert yes or no] 15. Is the patient's condition an intentionally self-inflicted injury or in the intention of suicide or any attempt thereat, while sane or insane?: [insert yes or no] 16. Is the patient's condition a result of homicide, frustrated homicide, or any attempt thereof, or physical injuries occasioned by the provocation of the Named Insured?: [insert yes or no] 17. State the hospital name where the patient has/have been confined/consulted in connection with the mentioned illness/loss: Name of Hospital: [insert name] Address (City and Province): [insert address] Date of Admission: [insert admission date] Date of Discharge: [insert discharge date] 18. Provide details of physicians to whom the patient had been referred or who attended to the patient: Name of Doctor: [insert name] Complete Address: [insert address] Dates Attended: [insert dates] Nature of Disease or Condition: [insert diagnosis] 19. Additional information relevant to this claim: [insert additional information] (Write a paragraph with any relevant clinical or contextual information that would assist claim adjudication; include only if applicable) PHYSICIAN’S DECLARATION I, [insert physician’s full name], a graduate of [insert medical college] in the year [insert year of graduation] with License No. [insert license number], hereby truthfully certify that the answers given above are full, complete and true. Physician’s Signature: [insert signature] Date Signed: [insert date] Place Signed: [insert place] Mobile Number: [insert mobile number] Clinic Address: [insert clinic address] Clinic Hours: [insert clinic hours] Printed name and signature of witness: [insert witness name and signature] (Never create or assume patient conditions, diagnoses, tests, provider details, or history — use only the transcript, contextual notes or clinical note as a reference. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been mentioned — just leave the placeholder or omit the section entirely. Follow the exact formatting and order of the example form.)