Fillable GOVERNMENT EMPLOYEES INSURANCE COMPANIES (Geico Claims)

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GOVERNMENT EMPLOYEES INSURANCE COMPANIES (Geico Claims)

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The Attending Physician Report is completed by your doctor. It is used to describe your medical care and how
those services are related to your injury. You will need to print this form, fill out the current date, your name,
the date of the accident and your claim number, and give the form to your doctor. Your doctor will need to
complete the form and return it to GEICO.
Instructions
(Form Below)
GOVERNMENT EMPLOYEES INSURANCE COMPANIES
ATTENDING PHYSICIAN’S REPORT
Date
Our Policyholder
Date of Accident
Claim No.
To assist us in determining what may be due the Applicant, the Attending Physician should complete this report and return it
directly to:
GOVERNMENT EMPLOYEES INSURANCE COMPANIES
CLAIMS DEPARTMENT
4201 SPRING VALLEY ROAD
DALLAS, TX 75244
1. Patient’s Name and Address:
2. Age:
3. Sex:
4. Occupation:
5. History of occurrence, as described by Patient:
6. Diagnosis and Concurrent Conditions:
8. Date when Patient first consulted you for this condition:
9. Has Patient ever had same or similar condition? YES NO If yes, state when and describe:
10. Is condition solely a result of this accident? YES NO If no, explain:
11. Is condition due to injury or sickness arising out of Patient’s employment? YES NO If yes, explain:
12. Will injury result in permanent disfigurement or disability? YES NO If yes, describe:
13. Was Patient hospitalized as a result of this injury? YES NO If yes, where:
14. Was Patient unable to work? YES NO
If yes, FROM: THROUGH:
15. If still disabled, date Patient should be able to return
to work:
16. Report of Services:
Date of Service
Place of Service
Description of Surgical or
Medical Service
Charges
$
$
$
TOTAL CHARGES TO DATE $
17. Is this Patient still under your care for this condition?
YES NO
Estimated Future Charges: $
18. Is any part of your bill covered by MEDICARE or MEDICAID? YES NO
Texas law requires the following to appear on this form.
“Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a
crime and may be subject to fines and confinement in state prison.”
____________________________________________________________________________________________________________________________________
Date Physician’s Name (print) Physician’s Signature IRS/TIN Identification No.
____________________________________________________________________________________________________________________________________
Number Street City or Town State Zip Code
C-257 TX (07-04) N
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GOVERNMENT EMPLOYEES INSURANCE COMPANIES (Geico Claims)

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Completed 11 February 2022

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