Fillable Form 869: If yes, can he / she (The Hartford)

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Form 869: If yes, can he / she (The Hartford)

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:
ATTENDING PHYSICIAN'S STATEMENT
(For Mental Health Claims)
Please fax the completed form to:
Fax Number: 8 33-357-5153
The Hartford
P.O.Box 14
869
Lexington, KY 40512-4869
Email: GBInformationUpload@thehartford.com
To Be Completed By The Employee
Patient Name:
Date of Birth:
Insured ID Number:
Patient Address: (Street, City, State & Zip Code)
To be completed by the Provider - (The patient is responsible for the completion of this form without expense to
the company)
Is the condition related to environmental and/or interpersonal
issues in his/her workplace?
Yes No
If "Yes," explain:
If yes, can he / she perform the same job at a different location / employer?
Yes No
Are these issues causing a disincentive to return to work with current Employer?
Yes No
DIAGNOSIS:
Primary Condition
:
DSM or ICD Code:
Secondary Condition: DSM or ICD Code:
Domain
I
Domain
II
Domain III
Domain
IV
Domain V Domain VI
WHODAS Score:
Patient Assessment Measures
(Provide
completed
assessment questionnaire)
Other Assessment Measures - please list the measure scale and
provide score (attach test results):
Current Self Reported Symptoms
Current Observed Symptoms (Clinical presentation, frequency,
severity, examples
):
CURRENT
MENTAL STATUS EXAMINATION
(Please circle or check current status or explain in “Comments”)
Examination Date:
Category
Description
Comments
Appearance
Well groomed Disheveled
Attitude
Cooperative Guarded Suspicious
Belligerent
Uncooperative
Speech
Normal Halted
Pressured Slurred
Incoherent
Thought Process
Logical/Coherent
Tangential Flight of ideas Circumst
anti
al
Mood WNL Depressed Anxious Irritable Euphoric
Affect Congruent Incongruent Blunted Flat Labile
Insight into illness
Absent Fair Good
Psychomotor Activity
WNL Agitation Retardation
Please check the statement that
indicates how this was assessed?
Attention
Intact
Impaired:
mild
moderate
severe Observed
Tested
Self-Reported
Concentration
Intact
Impaired: mild moderate
severe Observed
T
ested Self-Reported
Memory
Intact
Impaired : mild
moderate severe
Observed
Tested Self-Reported
CHANGES:
Indicate how this is a change from the patient's baseline. If the condition is chronic or long term, what and when did change occur?
LC-7592-9
Page 1 of 3
08 /2016
Clear Form
What are your patient's current abilities? What type of work can your patient perform?
Patient Name:
Insured ID Number:
Date of Birth:
FUNCTIONALITY:
List relevant treatment dates:
Date of last office visit:
Did you recommend your patient stop working? Yes No If Yes, on what date?
Are the symptoms of such severity to preclude the patient from social / occupational functioning? Yes No
When did the symptoms become severe enough to preclude social / occupational functioning?
If Yes, specify what work activities are impaired and how:
What is the expected duration of any work activity impairments?
Have you discussed a return to work goal with your patient?
Yes
No If No, please explain:
What is your target date for return to work for your patient?
Full time Part time
If part time, on what date will your patient be able to increase to full time?
If appropriate, provide examples of accommodations that would allow your patient to return to work:
In your opinion is the patient competent to endorse checks and direct the use of the proceeds thereof?
Yes No
Additional comments:
Date of onset of disability:
TREATMENT:
Date you first treated this patient for any condition:
Date you first treated this patient for this condition:
Date of onset of this condition:
Frequency of treatment:
Date of next office visit:
Page 2 of 3
LC-7592-9
08 /2016
Patient Name:
Date of Birth:
Insured ID Number:
TREATMENT CONTINUED:
Has patient been referred to any other mental health providers/physicians?
Y
es No
Provider Name:
If “yes”, please provide the following information:
Phone Number:
( )
Provider Address:
Are you coordinating care with this provider? Yes No
Was patient hospitalized or treated at a higher level of care for this condition?
Yes No
If “yes”, please provide information about any higher level of care:
Inpatient: Hospital/facility name Phone Number: ( )
Admission date: Discharge date:
Partial Hospital/Day Treatment/IOP: Hospital/facility name Phone Number: ( )
Admission date: Discharge date: Number of days per week: Number of hours per day:
Residential: Facility name: Phone Number: ( )
Admission date: Discharge date:
Medication (dose, change, date of change):
Response to medication:
STATUS (Please check one): In remission Improved Unchanged Retrogressed
Please provide a description of the most significant recent improvement and / or decompensation:
PROVIDER'S INFORMATION:
Provider’s Name:
Specialty:
License Number:
Address: (Street, City, State & Zip Code)
Telephone number:
( )
Degree:
Social Security Number or EIN Number:
Fax Number:
( )
Office Contact:
Office Contact Phone
( )
Provider's Signature:
Date Signed:
The Hartford® is underwriting companies Hartford Life and Accident Insurance Company and Hartford Life Insurance Company.
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries.
LC-7592-9
Page 3 of 3
08/2016
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Form 869: If yes, can he she (The Hartford)

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Completed 19 February 2021

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