Follow the steps to successfully complete and submit your form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the Patient’s Particulars section. Provide the patient's name, identification number, date of birth, sex, admission number, ward number, date of admission, and date of discharge in the respective fields.
3. In the Details of Patient’s Condition section, fill out the date of the accident. Then, provide a detailed description of how the accident occurred in the allocated space.
4. Describe the nature and severity of the patient’s injuries or disabilities in the next field. Be thorough to ensure accurate assessment.
5. Answer the questions regarding whether the injuries resulted from the described accident and if the patient was under the influence of alcohol or drugs at the time of the accident. If applicable, provide details on blood alcohol content and types of drugs.
6. Indicate if the injuries were self-inflicted. If so, provide a full description of the circumstances.
7. Answer whether the patient underwent any surgery. If yes, provide details such as the nature of the surgical procedure performed and the date of surgery.
8. Fill in the period of medical leave granted, specifying the period of total disability and the period of partial disability.
9. If applicable, indicate how long total or partial disabilities are expected to last.
10. Discuss if the patient suffered from any pre-existing conditions affecting the duration of disability. Provide details if applicable.
11. State if the patient consulted other doctors for the same injury before seeing the attending physician. Provide names and addresses of those doctors if yes.
12. Indicate if the patient was previously admitted to a hospital for the same injury, and if so, provide admission and discharge details.
13. Conclude by providing any additional information that could assist in the assessment of the claim.
14. Once all sections are completed, review the form for accuracy. Finalize by saving the changes, and choose to download, print, or share the form as needed.

Complete your Surrender/Withdrawal Form online today for efficient management of your account.