Get Have The Treating Physician Complete Section B Physician's Statement And Sign The Claim Form Or If

Filling out the accident injury claim form with precision is crucial for a smooth claims process. This guide provides step-by-step instructions for completing Section B, where your treating physician will document their statement and sign your claim form, either in-person or online.

Follow the steps to accurately complete the physician's statement and sign the claim form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the 'Policyholder Information'. Ensure you provide the policy number, first name, initial, last name, mailing address, city, state, and ZIP code. If this is a new permanent address, mark the relevant checkbox.
3. Complete the 'Patient Information' section. Input the phone number, social security number, first name, initial, last name, sex, and birth date. If the dependent child is a full-time student over 19, check the box and provide the school's name and contact information.
4. Answer the questions related to the accident. Provide the date of the accident and a detailed description of how it occurred. Indicate the location of the accident and if it was on-the-job, off-the-job, or other.
5. Specify if the patient was the driver in a motor vehicle accident. If yes, be sure to attach the police report as instructed.
6. If treatment was sought more than 50 or 100 miles from the patient's residence, and lodging for a relative was necessary during hospitalization, submit hotel receipts.
7. Have the treating physician complete Section B: Physician's Statement. The physician must provide their name, phone number, mailing address, dates of service, diagnosis code, procedure code, and relevant details about the incident.
8. The physician should answer all questions in Section B completely and provide their signature, along with the date and tax ID number.
9. After all sections are filled, review the form for any missing information. Save your changes, then download, print, or share the completed form as appropriate.

Ensure your claim is processed smoothly by completing the required documents online.