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Your doctor will need to complete the form and return it to GEICO. Form Below GOVERNMENT EMPLOYEES INSURANCE COMPANIES ATTENDING PHYSICIAN S REPORT Date Our Policyholder Date of Accident Claim No. To assist us in determining what may be due the Applicant the Attending Physician should complete this report and return it directly to CLAIMS DEPARTMENT ONE GEICO CENTER MACON GA 31296 1. Is this Patient still under your care for this condition Estimated Future Charges 18. Is any part of your bill covered by MEDICARE or MEDICAID Physician s Name print Physician s Signature IRS/TIN Identification No. Number C-257 RR 04-04 NS Street City or Town State Zip Code. Will injury result in permanent disfigurement or disability 13. Was Patient hospitalized as a result of this injury 14. Diagnosis and Concurrent Conditions 7. Date symptoms first appeared 8. Date when Patient first consulted you for this condition 9. Patient s Name and Address 2. Age 3. Sex 5. History of occurrence as described by Patient 4. Occupation 6. Has Patient ever had same or similar condition 10. Is condition solely a result of this accident YES NO If yes state when and describe If no explain 12. Instructions The Attending Physician Report is completed by your doctor. It is used to describe your medical care and how those services are related to your injury. You will need to print this form fill out the current date your name the date of the accident and your claim number and give the form to your doctor. Was Patient unable to work If yes FROM 16. Report of Services Date of Service THROUGH If yes explain If yes describe If yes where 15. If still disabled date Patient should be able to return to work Description of Surgical or Medical Service Charges TOTAL CHARGES TO DATE 17. Instructions The Attending Physician Report is completed by your doctor. It is used to describe your medical care and how those services are related to your injury. You will need to print this form fill out the current date your name the date of the accident and your claim number and give the form to your doctor. Was Patient unable to work If yes FROM 16. Report of Services Date of Service THROUGH If yes explain If yes describe If yes where 15. If still disabled date Patient should be able to return to work Description of Surgical or Medical Service Charges TOTAL CHARGES TO DATE 17.

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