Special Executive Financial Security

Policy number

6. Licensed Health Care Practitioner’s Statement of Chronic Illness (continued)

9. Have you designed a written Plan of Care for the patient that recommends the frequency and types of services most suitable to meet the patient’s need for Substantial Assistance or Continuous Supervision and the most appropriate types of providers for such services?

o Yes o No

If Yes, please include a copy of the Plan of Care when returning this form. If No, what treatment or services have been recommended?

10. Is the patient mentally capable of handling his or her own affairs? If No, date patient became mentally incapable of handling own affairs / / 11. Please provide information for any licensed health care practitioner/specialist referrals. Name of treating licensed health care practitioner

o Yes o No

Specialty

Address Reason for referral Referral date Address Reason for referral Referral date Address Reason for referral Referral date Address Reason for referral Referral date

/ / Name of treating licensed health care practitioner

Specialty

/ / Name of treating licensed health care practitioner

Specialty

SAMPLE Specialty

/ / Name of treating licensed health care practitioner

/ /

12. Additional comments

REMINDER: 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.

To be completed by the licensed health care practitioner Name of licensed health care practitioner (Please print.) Degree/Specialty Address: Street

Suite

City

State

ZIP

Telephone number

Fax number

X Licensed Health Care Practitioner’s signature

month / day / year

Page 9 of 9

COMB 115174-2

Ed. 10/2017