Get Continuance Waiver Of Premium Claim Form - Trustmark Insurance ...

Filling out the Continuance Waiver Of Premium Claim Form for Trustmark Insurance can be made easier with a clear understanding of its components. This guide provides step-by-step instructions to assist users in completing the form accurately online.

Follow the steps to complete your form successfully

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the patient's name and date of birth in the designated fields. Ensure that the spelling is accurate.
3. Fill in the policy number and address, including street, city, state, and zip code. Double-check all information for completeness.
4. In section one – 'History,' respond to the questions regarding the patient's symptoms and work cessation due to disability. Select 'Yes' or 'No' as applicable and provide additional details if needed.
5. Proceed to section two – 'Diagnosis.' Enter the diagnosis, subjective symptoms, and any objective findings such as tests or clinical results.
6. In section three – 'Dates of Treatment,' provide details about the patient's first and last visit and the frequency of visits. Choose from the options provided (weekly, monthly, etc.).
7. Complete section four by detailing the nature of treatment and indicating whether it is expected to improve the patient's function and employability.
8. In section five – 'Progress,' indicate the patient's current recovery status and their ability to perform daily activities.
9. If applicable, fill out section six – 'Cardiac' and section seven – 'Physical Impairment.' Choose the appropriate class that describes the patient's functional capacity.
10. For 'Mental/Nervous Impairment,' provide details if relevant, indicating the patient's ability to handle stress and interact socially.
11. Fill out the prognosis section, indicating whether the patient is currently totally disabled and any anticipated changes in their condition.
12. In the final sections, provide the attending physician's signature along with their degree, contact information, and any necessary remarks.
13. Once completed, you can save changes, download the form, print it, or share it as needed.

Start your online claim process by filling out the form today.