HARTFORD LIFE INSURANCE COMPANY ATTENDING PHYSICIAN S STATEMENT OF DISABILITY Clear Form To be completed by the Employee Name of patient Address of patient Social Security Number Street City D.
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How to fill out the Hartford Lc 7135 Form online
Filling out the Hartford Lc 7135 form online is a straightforward process that requires attention to detail. This form is essential for documenting a patient's disability and requires information from both the patient and the attending physician.
Follow the steps to complete the Hartford Lc 7135 Form online effectively.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Carefully enter the name of the patient in the designated field. This should be the person for whom the disability claim is being filed.
- Provide the patient's address, including the street, city, state or province, and zip code or postal code.
- Input the patient's Social Security Number and date of birth.
- Enter the employer’s name, along with the division if applicable. This is important for correlating the employee with their workplace.
- The patient must authorize the release of their information by signing in the appropriate area and indicating the date of signature.
- For the attending physician section, indicate whether the patient’s condition is due to illness or injury, and if it involves pregnancy, provide the expected date of delivery.
- Document the primary diagnosis, secondary diagnosis, and applicable ICD-9 codes.
- List the subjective symptoms and any relevant test results, ensuring to include dates and results for each test conducted.
- Provide details regarding the treatment history, including the dates of first and recent treatment, as well as how often the patient has been seen.
- Indicate if the patient has been referred to another physician, and include their contact information if applicable.
- Fill in any surgical procedures and hospitalization details if they occurred because of the condition.
- Complete the impairment section by detailing any limitations the patient has in specified activities.
- If necessary, include details about the patient's psychiatric impairment and their competences related to endorsing checks.
- Finally, enter the attending physician’s name, contact information, license number, and signature along with the date signed.
- Once all sections are complete, save any changes made. You can then download, print, or share the form as needed.
Start filling out the Hartford Lc 7135 Form online today to manage your disability claims efficiently.
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