Fillable Group Long-Term Disability Claim Form (University of Texas System)

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Group Long-Term Disability Claim Form (University of Texas System)

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Return to Blue Cross and Blue Shield of Texas at:
Attention Claims Department
P.O. Box 7071
Downers Grove, IL 60515
Group Long-Term Disability Claim Form
Phone Number: (866) 628-2606
Fax: (877) 404-6457
NOTE: All portions of this form package must be completed to avoid undue delay in processing claimant's
request for benefits.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES
AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR
CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS
A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
(Not enforceable in Oregon or Virginia.)
APPLICATION FOR LTD BENEFITS — Employee's Instructions
A. Complete employee claim statement in full, and be sure to sign the Authorization. This will allow Blue Cross
and Blue
Shield of Texas (BCBSTX) or its representative to secure additional information if necessary to
make a decision on your claim.
B. Give this form to the physician treating you. (If more than one physician is treating you, obtain additional
forms from your employer.)
When your physician returns the completed form to you:
A. Attach:
• Acopyofyourbirthcertificate(onlyifdisabilityisindefiniteandyouareoverage50)
• AcopyofSocialSecurityandotherincomeentitlementawards;and
B. Return with all attachments, to BCBSTX at address above.
ATTENDING PHYSICIAN'S STATEMENT (APS) — Physician's Instructions
As soon as the claimant gives you this form:
A. Complete the APS on page 3 of the form in its entirety, being careful to answer each question.
If the answer is none, or if the question is not applicable, please so indicate.
B. As soon as you have fully completed the form, sign, date, and return to the claimant. Our timely review of
this claim for disability benefits depends on you. Thank you for your prompt response.
UTSYSTEM GFZ71778
Page 1 of 3
R040119 I X6136_uts_BCBSTX
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Employee’s Claim Statement
To be Completed by Employee
1. Full Name (Last, First, Middle Init.) 2. Maiden Name 3. Alias Name 4. Benefits ID No. 5. Phone Number
( )
6. Address City State Zip Code
7. Date of Birth 8. Height 9. Weight 10. Sex 11. Marital Status 12. Spouse's date of birth 13. Is spouse
employed?
14. Number of children
15. List names and dates of birth of unmarried children who have not finished high school.
(Under age 19)
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16. Employer's Name 17. Group Policy No.
18. Occupation (List the duties of your occupation at the time of disability)
19. Date of accident or date 20. I have been unable to work 21. I returned to work on 22. I returned to work on a full
first noticed symptoms because of the disability a part time basis on: time basis on:
of illness: since:
23. Is your accident or illness 24. Have you or do you intend to file a Workers’ Comp. Claim?
q Yes q No
related to your occupation? If “yes,” explain
q Yes q No
25. Describe how and where accident occurred or describe the onset and nature of your illness.
26. Date you were 27. Treated by:
first treated for
your illness or
injury.
28. Have you ever 29. Treated by:
had the same or
similar condition
in the past?
30. Describe other income you are receiving:
Date Date
Yes No Amount Began Term.
q q
Type
Social Security (disability or retirement)
$__________ __________ __________
q q State disability $__________ __________ __________
q q Retirement (normal, early or disability) $__________ __________ __________
q q Workers' Compensation $__________ __________ __________
q q Group disability benefits $__________ __________ __________
q q Other (describe) $__________ __________ __________
31. Have you applied, or do you plan to apply for benefits described above? q Yes q No
Type Date application filed
Type Date application filed
Mo. Day Year
If yes complete No. 29.
q Yes q No
Mo. Day Year
Mo. Day Year Mo. Day Year
Mo. Day Year
q M
q F
qYes
qNo
q Single q Married
q Widowed q Divorced
Mo. Day Year
First Name
Hospital: ________________________________________________________________________________
Name Street Address City State Zip Code
Doctor: ________________________________________________________________________________
Name Street Address City State Zip Code
Hospital: ________________________________________________________________________________
Name Street Address City State Zip Code
Doctor: ________________________________________________________________________________
Name Street Address City State Zip Code
Signature of Employee
Date
Mo. Day Year
–
ft. in.
32. If your request for benefits is approved, do you want us to withhold amounts from each benefit for Federal Income Tax
purposes?
q Yes q No If yes, please complete and attach IRS Form W4S.
AUTHORIZATION: I authorize any medical professional or provider, hospital, medical facility, clinic, pharmacy,
Government Agency or insurance company to disclose to Blue Cross and Blue Shield of Texas
's (BCBSTX) claim
department, reinsurers or authorized representatives information about my medical history or treatment and/or to furnish
copies of my hospital and/or medical records including information concerning advice, care or treatment for any condition,
including but not limited to drug or alcohol use or abuse, mental illness, HIV (AIDS Virus) or other sexually
transmitted diseases. I also authorize my employer to disclose all information needed to process my claim.
This authorization expires on the date I receive notice of BCBSTX's final claim decision. I may revoke this
authorization at any time, but such a revocation will have no effect on any actions taken by BCBSTX prior to receipt of the
revocation. Information provided pursuant to this authorization may be redisclosed by the recipient and no longer
subject to the protections of the HIPAA Privacy Rule. A photocopy of this authorization is as valid as the original. I understand
that I should retain a copy of this authorization for my records and that my personal representative or I have a right to obtain a
copy of my authorization from BCBSTX. If my answers on this claim form are incorrect or untrue, or if I refuse to sign
this authorization, BCBSTX has the right to deny my claim.
–
lbs.
UTSYSTEM GFZ71778
Page 2 of 3
R040119 I X6136_uts_BCBSTX
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Attending Physicians Statement
Name of patient Date of Birth
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(a) When did symptoms first appear or (b) Date patient ceased work (c) Has patient ever had same or similar condition?
accident happen? because of disability? q Yes If "Yes" state when and describe
q No
(d) Is condition due to injury or sickness (e) Names and addresses of other treating physicians
arising out of patient's employment?
q Yes q No q Unknown
(a) Date of first visit (b) Date of last visit (c) Frequency q Weekly q Monthly q Other (Specify)
(d) Nature of treatment (Including surgery and medications prescribed, if any)
(a) Is patient now totally disabled?
PATIENT'S JOB qYes q No (b) Date patient became disabled due to
ANY OTHER WORK
q
Yes
q
No
present illness
(c) When do you expect a fundamental or marked change in the future?
q 1 Mo. q 1-3 Mo. q 3-6 Mos. q Never. Applies To: q Patient's job q Other Work
(a) Is patient a suitable candidate PATIENT'S JOB ANY OTHER WORK (b) Can present job be modified to allow for
for occupational rehabilitation? q Yes q No q Yes q No
handling with impairment?
q Yes q No
(c) When could trial employment commence? Date q Full-time Date q Full-time
PATIENT'S JOB q Part-time ANY OTHER WORK q Part-time
(Limitations, Therapy, etc.)
Name (Attending Physician) Print Degree Telephone ( )
Fax #: ( )
Street Address City or Town State Zip Code
Signature Date
(a) Has patient q Recovered? q Improved? (b) Is patient q Ambulatory? q House confined?
q Unchanged? q Retrogressed? q Bed confined? q Hospital confined?
(c) Has patient been hospital confined? q Yes q No Confined from through
If, yes, give Name and Address of Hospital:
(a) Diagnosis (Including complications)
Please submit all office notes in regard to this condition* (b) Subjective symptoms
(c) Objective findings (Including current x-rays, EKG's, laboratory data and any clinical findings?)
(b) Mental Impairments (If applicable)
(a) Please define "stress" as it applies to this claimant.
(b) What stress and problems in interpersonal relations has claimant had on job?
q Class 1 - Patient is able to function under stress and engage in interpersonal relations (no limitations)
q Class 2 - Patient is able to function in most stress situations and engage in most interpersonal relations (slight limitations)
q Class 3 - Patient is able to engage in only limited stress situations and engage in only limited interpersonal relations (moderate limitations)
q Class 4 - Patient is unable to engage in stress situations or engage in interpersonal relations (marked limitations)
q Class 5 - Patient has significant loss of psychological, physiological, personal and social adjustment (severe limitations)
Remarks:
(a) Physical Impairments (*As defined in Federal Dictionary of Occupational Titles).
q Class1-Nolimitationoffunctionalcapacity;capableofheavywork*Norestrictions.(0-10%)
q Class2-Mediummanualactivity*(15-30%)
q Class3-Slightlimitationoffunctionalcapacity;capableoflightwork*(35-55%)
q Class4-Moderatelimitationoffunctionalcapacity;capableofclerical/administrative(sedentary*)activity.(60-70%)
q Class5-Severelimitationoffunctionalcapacity;incapableofminimum(sedentary*)activity.(75-100%)
Remarks:
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* Please submit bill for records
with this claim.
UTSYSTEM GFZ71778
Page 3 of 3
R040119 I X6136_uts_BCBSTX
(a) Functional capacity (*American Heart Ass’n.)
q Class 1 (No limitation) q Class 2 (Slight limitation)
q Class 3 (Marked limitation) q Class 4 (Complete limitation)
(b) Blood Pressure (last visit)
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
R040119 | Z6291_BCBSTX
Page 1 of 2
The laws of some states require us to furnish you with the following notice:
FOR APPLICATIONS AND CLAIMS:
Colorado: It is unlawful to knowingly provide false,
incomplete, or misleading facts or information to an
insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance, and
civil damages. Any insurance company or agent of
an insurance company who knowingly provides false,
incomplete, or misleading facts or information to a
policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with
regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado division of
insurance within the department of regulatory agencies.
District of Columbia: WARNING: It is a crime to
provide false or misleading information to an insurer
for the purpose of defrauding the insurer or any other
person. Penalties include imprisonment and/or fines. In
addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by
the applicant.
Florida: Any person who knowingly and with intent to
injure, defraud, or deceive any insurer files a statement
of claim or an application containing any false,
incomplete, or misleading information is guilty of a felony
of the third degree.
Hawaii: For your protection, Hawaii law requires you be
informed that presenting a fraudulent claim for payment
of a loss or benefit is a crime punishable by fines or
imprisonment, or both.
Kentucky: Any person who knowingly and with intent
to defraud any insurance company or other person files
an application for insurance or a statement of claim
containing any materially false information or conceals,
for the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act,
which is a crime.
Louisiana: Any person who knowingly presents a false
or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to fines
and confinement in prison.
Maine & Washington: It is a crime to knowingly
provide false, incomplete, or misleading information to
an insurance company for the purpose of defrauding the
company. Penalties include imprisonment, fines and
denial of insurance benefits.
Maryland: Any person who knowingly or willingly
presents a false or fraudulent claim for payment of a loss
or benefit or who knowingly or willfully presents false
information in an application for insurance is guilty of a
crime and may be subject to fines and confinement in prison.
New Mexico: Any person who knowingly presents a
false or fraudulent claim for payment of a loss or benefit
or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to
civil fines and criminal penalties.
Ohio: Any person who, with intent to defraud or
knowingly that he is facilitating a fraud against an insurer,
submits an application or files a claim containing a false
or deceptive statement is guilty of insurance fraud.
Oklahoma: Any person who knowingly, with intent to
injure, defraud or deceive any insurer, makes a claim
for the proceeds of an insurance policy containing false,
incomplete or misleading information is guilty of a felony.
Pennsylvania: Any person who knowingly and with
intent to defraud any insurance company or other person
files an application for insurance or statement of claim
containing any materially false information or conceals for
the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act,
which is a crime and subjects such person to criminal
and civil penalties.
Puerto Rico: Any person who knowingly and with the
intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the
presentation of a fraudulent claim for the payment of
a loss or any other benefit, or presents more than one
claim for the same damage or loss, shall incur a felony
and, upon conviction, shall be sanctioned for each
violation with the penalty of a fine of not less than five
thousand dollars($5,000) and not more than ten thousand
dollars ($10,000), or a fixed term of imprisonment for
three (3) years, or both penalties. Should aggravating
circumstances be present, the penalty thus established
may be increased to a maximum of five (5) years,
if extenuating circumstances are present, it may be
reduced to a minimum of two (2) years.
Rhode Island: Any person who knowingly presents a
false or fraudulent claim for payment of a loss or benefit
or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to
fines and confinement in prison.
Tennessee: It is a crime to knowingly provide false
incomplete or misleading information to an insurance
company for the purpose of defrauding the company.
Penalties include imprisonment, fines and denial of
insurance benefits
Virginia: It is a crime to knowingly provide false,
incomplete or misleading information to an insurance
company for the purpose of defrauding the company.
Penalties include imprisonment, fines and denial of
insurance benefits.
Administrative Offices: 701 E. 22nd Street, Lombard, IL 60148
Fraud Notices
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
The laws of some states require us to furnish you with the following notice:
FOR CLAIMS ONLY:
Alaska: A person who knowingly and with
intent to injure, defraud, or deceive an
insurance company files a claim containing
false, incomplete, or misleading information
may be prosecuted under state law.
Arizona: For your protection, Arizona law
requires the following statement to appear on
this form. Any person who knowingly presents
a false or fraudulent claim for payment of a loss
is subject to criminal and civil penalties.
Arkansas: Any person who knowingly
presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false
information in an application for insurance is
guilty of a crime and may be subject to fines
and confinement in prison.
California: For your protection California law
requires the following to appear on this form.
Any person who knowingly presents 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.
Delaware: Any person who knowingly, and
with intent to injure, defraud or deceive any
insurer, files a statement of claim containing
any false, incomplete or misleading information
is guilty of a felony.
Idaho: Any person who knowingly, and with
intent to defraud or deceive any insurance
company, files a statement or claim containing
false, incomplete, or misleading information is
guilty of a felony.
Indiana: A person who knowingly and with
intent to defraud an insurer files a statement
of claim containing any false, incomplete, or
misleading information commits a felony.
Minnesota: A person who files a claim with
intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
New Hampshire: Any person who, with a
purpose to injure, defraud or deceive any
insurance company, files a statement of claim
containing any false, incomplete or misleading
information is subject to prosecution and
punishment for insurance fraud, as provided in
RSA 638:20.
New Jersey: Any person who knowingly files
a statement of claim containing any false or
misleading information is subject to criminal
and civil penalties.
Texas: 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.
FOR APPLICATIONS ONLY:
Massachusetts: Any person who knowingly
presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false
information in an application for insurance is
guilty of a crime and may be subject to fines
and confinement in prison.
New Jersey: Any person who includes
any false or misleading information on an
application for an insurance policy is subject to
criminal and civil penalties.
R040119 | Z6291_BCBSTX
Page 2 of 2
Administrative Offices: 701 E. 22nd Street, Lombard, IL 60148
Fraud Notices
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
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Group Long-Term Disability Claim Form (University of Texas System)

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Completed 13 January 2021

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