"Physician Statement Stroke Claim Form - Cblife"

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Colorado Bankers Life Insurance Company®
Attn: Claims Department
5990 Greenwood Plaza Blvd., Suite 325
Greenwood Village, CO 80111
800.367.7814
Fax: 855.777.5433
Email: Claims@CBLife.com
CBLife.com
ATTENDING PHYSICIAN STATEMENT
FOR CRITICAL CONDITION ACCELERATED BENEFIT
PHYSICIAN STATEMENT
STROKE CLAIM FORM
This form is provided to you, the physician, to be completed on behalf of your patient. The completion of this form is necessary for your patient to be
considered for Accelerated Benefits under their policy. Attached please find authorization for the release of any medical information. All sections must
be fully answered and this form must be signed and dated. If you have any questions, please contact the Claims Department.
Patient name ____________________________________ Social Security Number ______ - _____ - ______ Date of birth _____ / ______ / ______
1. Diagnosis ____________________________________________________________________________________________________________
a. Date condition first diagnosed__________________________ b. Date patient advised of condition______________________________
c. Prognosis _____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
d. Course of treatment ____________________________________________________________________________________________
_____________________________________________________________________________________________________________
2. Was diagnosis of Cerebrovascular accident made?
 yes
 no
If YES, on what date did the CVA occur? ______ / _______ / _______
What was the cause of the stroke (if known): ___________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Please describe the residual neurological deficits: ________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
How long has the neurological deficits persisted? ________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Please list the information of who made the diagnosis:
Name _________________________________________________________________________________________________________
Address______________________________________________ City_________________________ State ____________ Zip_________
Phone ( _______ ) - _________________________
3. Please provide a copy of the CT Scan or MRI results (if available).
4. Please describe and include dates of any predisposing disorders or risk factors (including family history) your patient had for this condition:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
PS-Stroke 09-15 Page 1 of 3
Colorado Bankers Life Insurance Company®
Attn: Claims Department
5990 Greenwood Plaza Blvd., Suite 325
Greenwood Village, CO 80111
800.367.7814
Fax: 855.777.5433
Email: Claims@CBLife.com
CBLife.com
ATTENDING PHYSICIAN STATEMENT
FOR CRITICAL CONDITION ACCELERATED BENEFIT
PHYSICIAN STATEMENT
STROKE CLAIM FORM
This form is provided to you, the physician, to be completed on behalf of your patient. The completion of this form is necessary for your patient to be
considered for Accelerated Benefits under their policy. Attached please find authorization for the release of any medical information. All sections must
be fully answered and this form must be signed and dated. If you have any questions, please contact the Claims Department.
Patient name ____________________________________ Social Security Number ______ - _____ - ______ Date of birth _____ / ______ / ______
1. Diagnosis ____________________________________________________________________________________________________________
a. Date condition first diagnosed__________________________ b. Date patient advised of condition______________________________
c. Prognosis _____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
d. Course of treatment ____________________________________________________________________________________________
_____________________________________________________________________________________________________________
2. Was diagnosis of Cerebrovascular accident made?
 yes
 no
If YES, on what date did the CVA occur? ______ / _______ / _______
What was the cause of the stroke (if known): ___________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Please describe the residual neurological deficits: ________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
How long has the neurological deficits persisted? ________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Please list the information of who made the diagnosis:
Name _________________________________________________________________________________________________________
Address______________________________________________ City_________________________ State ____________ Zip_________
Phone ( _______ ) - _________________________
3. Please provide a copy of the CT Scan or MRI results (if available).
4. Please describe and include dates of any predisposing disorders or risk factors (including family history) your patient had for this condition:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
PS-Stroke 09-15 Page 1 of 3
5. Contact information for Primary Care Physician:
Physician name ____________________________________________________ Phone Number ( _______ ) - _____________________________
Address __________________________________________________ City ______________________________ State ______ Zip code ________
Please list any other physicians consulted or hospitals attended by your patient for this or any other related disorder:
Physician name ____________________________________________________ Phone Number ( _______ ) - _____________________________
Address __________________________________________________ City ______________________________ State ______ Zip code ________
Physician name ____________________________________________________ Phone Number ( _______ ) - _____________________________
Address __________________________________________________ City ______________________________ State ______ Zip code ________
Name of Hospital ___________________________________________________ Phone Number ( _______ ) - _____________________________
Address __________________________________________________ City ______________________________ State ______ Zip code ________
Hospitalization dates:
From _____ / ______ / ________ to _______ / _______ / _______
Name of Rehabilitation Facility ________________________________________ Phone Number ( _______ ) - _____________________________
Address __________________________________________________ City ______________________________ State ______ Zip code ________
Hospitalization dates:
From _____ / ______ / ________ to _______ / _______ / _______
6. Please provide details of your patient’s tobacco use including amount per day and date last used: ____________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
7. Please provide any other information that would be helpful in the assessment of your patient’s claim: ________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Signature of Physician _____________________________________________ Date _______________ Phone ______________________________
Printed Name of Physician _________________________________________ Address ________________________________________________
________________________________________________
________________________________________________
PS-Stroke 09-15 Page 2 of 3
FRAUD WARNING NOTICE
The laws of some states require us to furnish you with the following notice:
Alabama – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confine-
ment in prison, or any combination thereof.
Arkansas, Louisiana, Massachusetts, Rhode Island – Any person who knowingly presents a false or fraudulent claim for pay-
ment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
Colorado – It is unlawful to knowingly provide false, incomplete, or misleading material facts or information to an insurance
company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines,
denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false,
incomplete, or misleading material facts or information to a policyholder or claimant for the purpose of defrauding or attempt-
ing to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be
reported to the Colorado Division of Insurance within the department of regulatory agencies.
District of Columbia – WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of de-
frauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance
benefits if false information materially related to a claim was provided by the applicant.
Florida – Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an ap-
plication containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Hawaii – For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
Kentucky – Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or a statement of claim containing any materially false information or conceals, for the purpose of misleading, informa-
tion concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
Maine, Tennessee, Virginia, Washington – It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance
benefits.
Maryland – Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines
and confinement in prison.
Minnesota – A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an
insurer is guilty of a crime.
New Jersey – Any person who includes any false or misleading information on an application for an insurance policy is subject
to criminal and civil penalties.
New Mexico – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penal-
ties.
Ohio – Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application
or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma – Any person who knowingly, with intent to injure, defraud or deceive any insurer, makes a claim for the proceeds of
an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Pennsylvania – Any person who knowingly and with intent to defraud any insurance company or other person files an applica-
tion for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person
to criminal and civil penalties.
Puerto Rico – Any person who knowingly and with the intention of defrauding presents false information in an insurance ap-
plication, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or
presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for
each violation with the penalty of a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars
($10,000) or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present,
the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may
be reduced to a minimum of two (2) years.
All Other States – Any person who knowingly presents a false statement in an application for insurance may be guilty of a crimi-
nal offense and subject to penalties under state law.
Products and services are underwritten and/or provided by Colorado Bankers Life Insurance Company
®
Fraud Notice 11-14 REV 08-15 Page 3 of 3
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