Attending Physician Statement
To be completed by the treating physician.
_________________________________________________________________________ ____ /____ /____
Name of Patient Patient’s Date of Birth (MM/DD/YY)
_________________________________________________________________________ ______________________________
Patient’s Diagnosis ICD Code
____ /____ /____ ____ /____ /____ ____ /____ /____ ____ /____ /____
Date of rst examination or Date of latest treatment Date symptoms rst appeared Date ended
consultation for this diagnosis
_______________________________________________________________________________________________________________________
Please list all dates of examination/treatment for this condition from initial consultation to present
Has the patient previously received medication or No Yes
other treatment for this condition or for a related
condition by you or any other physician?
_______________________________________________________________________________________________________________________
If so, please provide exact dates and details
Was patient hospitalized as a result of sickness/injury? No Yes ____ /____ /____ to ____ /____ /____
If hospitalized, dates conned
______________________________
Name of Hospital
Was patient treated by any other medical professional? No Yes ______________________________
If yes, by whom?
Did the sickness/injury result in medical restrictions so No Yes
disabling to cause the cancellation of the trip?
___________________________________________________________________________ ____ /____ /____
Name of Physician (print) Date Completed
___________________________________________________________________________
Signature of Physician
_______________________________________________________________________________________________________________________
Address of Physician
_____________________ _____________________
Telephone Fax
Please have the patient sign the “Authorization for Release of Medical Information,” as we may request a copy of the patient’s medical records.
Authorization for Release of Medical Information
In order to process a claim, I authorize any physician, hospital or other medical provider to release to Aon Afnity, or its representative any information
regarding my medical history, symptoms, treatment, examination results or diagnosis. Additionally, I authorize Aon Afnity to disclose the information
which I have provided in this form to travel companies, such as airlines, hotels, cruise lines and car rental companies, for the limited purpose of obtaining
refunds related to my claim. A photocopy of this authorization shall be considered as effective and valid as the original. This authorization shall be
considered valid for the duration of the claim, but not to exceed one year from the date signed. I understand I have the right to receive a copy of this
authorization.
____ /____ /____ ____ /____ /____ _______________________________________________________________
Date Completed Date of Birth Signature of person suffering illness/injury (or legally authorized representative)
__________________________________ ______________________________
Claim Contact Name Contact Phone Number
Aon Afnity Travel Practice
