Attending Physician’s Statement – Initial
Please fax the completed form to:
Fax Number: 833-357-5153
The Hartford
P.O. Box 14869
Lexington, KY 40512-4869
Email: GBInformationUpload@thehartford.com
Patient Last Name:
The patient is responsible for completion of this form without expense to the company
Patient First (or Preferred) Name: Date of Birth: Claim Id Number:
Condition
Patient’s condition is a result of:
Illness Injury
Pregnancy
If illness or injury, is condition related to:
Work Activity
Motor Vehicle Accident
Intentional/Self-Inflicted
If pregnancy, what is date of delivery?
_ _ /_ _ /_ _ _ _
MM DD YYYY
Actual
Estimated
Condition onset:
_ _ /_ _ /_ _ _ _
MM DD YYYY
First day recommended
out of work:
_ _ /_ _ /_ _ _ _
MM DD YYYY
Projected return to work
date:
_ _ /_ _ /_ _ _ _
MM DD YYYY
Office visit to complete this form:
_ _ /_ _ /_ _ _ _
MM DD YYYY
In Person
Telemedicine
Disabling Diagnosis(es) and Impact to Function
ICD 10 Codes
Please provide most specific codes:
Description of corresponding symptoms
__________________________________
__________________________________
Co-Morbid Conditions with Impact to Diagnosis
None
Diabetes
Hypertension
COPD
Opioid Usage
Heart Disease
Obesity
Arthritis
Psoriasis
Asthma/Bronchitis
Auto-Immune Disease
Other ____________
Mental Health
Cognitive Impairment
In your opinion is the patient competent
to endorse checks and direct the use of
proceeds?
Yes No
Treatment Plan
Conservative treatment Bed Rest Palliative care Hospice Care
Hospitalization Admittance date: _ _ /_ _ /_ _ _ _
MM DD YYYY
Discharge date: _ _ /_ _ /_ _ _ _
MM DD YYYY
Next/Another appointment Date: _ _ /_ _ /_ _ _ _ In Person Telemedicine
MM DD YYYY
Physical/Occupational therapy
times per week until _ _ /_ _ /_ _ _ _
MM DD YYYY
Actual Estimated
Surgery Date: _ _ /_ _ /_ _ _ _
CPT Code(s):
Referral to a specialist Type: _________________________ Contact Info:_________________________________
Current Medications (related to condition or impacting function)
None Over counter medications: ____________________________________________________________
Prescription medications Name(s): ____________________________________________________________
Impacting function? Yes No If yes, why? __________________________________________________
Chemotherapy Radiation Start Date: _ _ /_ _ /_ _ _ _
MM DD YYYY
End Date: _ _ /_ _ /_ _ _ _
MM DD YYYY
LC-7135-13
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including underwriting companies Hartford Life and Accident Insurance
Company and Hartford Fire Insurance Company. Home Office is Hartford, CT. The Hartford is the administrator for certain group benefits business
written by Aetna Life Insurance Company and Talcott Resolution Life Insurance Company (formerly known as Hartford Life Insurance Company). The
Hartford also provides administrative and claim
services for employer leave of absence programs and self-funded disability benefit plans.
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