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Get Guardian Attending Physicians Statement Form Gg 213

Attending Physician s Statement Send to Group Long Term Disability Claims P. O. Box 26025 Lehigh Valley PA 18002-6025 For Customer Service 800 538-4583 Fax 610 807-8221 Email GroupLTDClaims GuardianLife. com EMPLOYEE SECTION 1. Employee Name 2. DOB / / 5. Address City 3. Plan State 4. Social Security Zip 6. Phone 8. Occupation AUTHORIZATION 9. I authorize any physician medical practitioner hospital clinic other health facility consumer reporting.

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