Fillable DISABILITY - CONTINUATION CLAIM FORM (LINECO)

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DISABILITY - CONTINUATION CLAIM FORM (LINECO)

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The DISABILITY - CONTINUATION CLAIM FORM (LINECO) form is 1 page long and contains:

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DISABILITY - CONTINUATION CLAIM FORM
***********This form should only be used to continue an already approved disability*****************
PHYSICIAN STATEMENT
Patient Name: __________________________________ Member ID: ________________________
Patient Date of Birth (DOB): _____ / ______ / _______
Nature of Illness / Injury: _____________________________________________________________
Date of 1
st
Treatment: __________________ Date of Last Treatment: ____________________
Date of Next Appointment: ____________________
Date Patient May Return to Work (if unknown, estimate): __________________________________
Nature of Surgical Procedure Performed: ________________________________________________
Patient Has Been Continuously Disabled From _______________ Through _____________________
Remarks/Restrictions: _____________________________________________________________
Was Patient Referred to another Physician /Specialist (if Yes): Name: _________________________
Phone Number: ______________________
Date: _______________ Physicians Signature: _________________________________________
Physicians Name (please print): ________________________________
Physicians Licensure/Degree: __________________________________
Physicians Address: _______________________________________________________________
___________________________________________________________________________________
Physicians Tax ID: ___________________ Physicians Phone Number: ____________________
Physicians Fax Number: _____________________
Please return this form via fax to 630-916-6847 / Attn: Disability Benefits
The Below Information Should Be Completed By Your
Attending Physician Only
Completing Physician: I certify that the statements hereon are complete and accurate to the b
est of my knowledge.
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DISABILITY - CONTINUATION CLAIM FORM (LINECO)

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Completed 15 January 2021

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