Mrs. Kasmikha Family Financial Security
Licensed Health Care Practitioner’s Statement for Chronic Illness Benefit
Policy number
Instructions for Licensed Health Care Practitioner Please complete section 6. The licensed health care practitioner completing this form should be the licensed health care practitioner currently treating the patient for the chronic condition. Please include ALL pertinent consultation reports, medication sheets, test/ diagnostic reports, functional evaluations, and clinical data from the date ADL dependencies secondary to chronic illness or cognitive impairment commenced. Send the completed form, along with the Plan of Care (if applicable) directly to us at: Prudential Life Claim Division PO Box 13902 Philadelphia, PA 19176 6. Licensed Health Care Practitioner’s Statement of Chronic Illness Name of patient Date of birth Primary diagnosis Secondary diagnosis Onset of symptoms/Date of accident / / Details of the patient’s significant impairments secondary to their chronic condition
SAMPLE
Relevant surgical interventions and dates of procedures: Surgical Procedure
Date Completed / /
/ / / /
1. Has the patient had a formal physical/occupational evaluation related to the chronic condition?
o Yes o No
If Yes, please list the type(s) of evaluation(s) and dates of services. Type of Evaluation
Date Completed
End Date of Therapy
/ / / / / /
/
/
/ / / /
2. Are you currently treating the patient for this condition or illness?
o Yes o No
First visit
/
/
Most recent visit
/
/
Next scheduled visit
/
/
How frequently is the patient seen in your office? o Weekly o Monthly o Other (specify) 3. Has your patient ever been admitted to a hospital, nursing home, skilled facility, acute rehabilitation facility, or assisted living facility?
o Yes o No
If Yes, please provide the following information: Name of Facility
Reason for Admission
Date of Admission
Date of Discharge
/ / / / / /
/ / /
/ / /
(continued)
Page 7 of 9
COMB 115174-2
Ed. 10/2017
Made with FlippingBook PDF to HTML5