Get Attending Physician39s Statement - Penn Treaty

Completing the Attending Physician's Statement is a critical part of expediting your patient’s claim process. This form gathers essential information about the patient's medical condition and care needs. Following this guide will help ensure that you fill out the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to acquire the form and open it in your document management tool.
2. Fill in the patient’s name, policy number, and date of birth in the designated fields at the top of the form.
3. Indicate whether you are the patient’s primary care physician (PCP) by selecting 'yes' or 'no'. If 'no', please specify your specialty.
4. If the patient has been referred to another physician, provide the name, telephone number, and specialty of that physician.
5. Record the date of your last consultation with the patient and the reason for that visit.
6. List the diagnoses or relevant ICD-9 codes that justify the need for care, along with the onset dates.
7. If applicable, specify any activity restrictions for the patient by selecting 'yes' or 'no'. If 'yes', provide details on the restrictions.
8. Under the level of care section, select the appropriate option regarding the patient's care needs, such as home care or assisted living.
9. Indicate the expected duration of care in days or weeks.
10. Sign and date the form at the end, ensuring that you include your name, telephone number, street address, and fax number.
11. Once completed, you can save your changes, download, print, or share the form as needed.

Complete the ATTENDING PHYSICIAN'S STATEMENT online to ensure a smooth claims process.