HEALTH, ACCIDENT, & DISABILITY CLAIM FORM
Customer Service Center 1-888-671-6771
ntalife.com
National Teachers Associates Life Insurance Company
POLICY OWNER’S NAME DATE OF BIRTH
POLICY #
PATIENT NAME
NAME AND ADDRESS OF REFERRING PHYSICIAN (IF APPLICABLE)
NAME AND ADDRESS OF HOSPITAL WHERE SERVICES RENDERED (IF APPLICABLE) DATE ADMITTED DATE DISCHARGED
_________/ ________ / ________ _______/________/________
DATE OF FIRST SYMPTOM (IF SICKNESS)
OR
DATE OF INJURY
DATE FIRST CONSULTED FOR THIS CONDITION
_________ / ________ / ________
HAS PATIENT EVER HAD SAME OR SIMILAR SYMPTOMS? Yes No
IF “YES” PLEASE GIVE THE DATE:
_________ / ________ / ________
_________ / ________ / ________
Diagnosis or Nature of Sickness or Injury ICD-9 or ICD-10 Code
1.
2.
3.
Is this condition related to pregnancy? LMP _____/_____/_____ Date of Delivery _____/_____/_____ Method of delivery:
Vaginal
C-Section
Yes
No
Date of Place of Describe Medical Procedures
Service Service CPT Code and Services Provided Charges
For Disability Claims, please fill out the following:
DATES OF TOTAL DISABILITY (UNABLE TO WORK)
______/______/______ to______/______/______
DATES OF PARTIAL DISABILITY
______/______/______ to ______/______/______
DATE PATIENT RELEASED TO RETURN
TO WORK
PROVIDER NAME PROVIDER ADDRESS PHONE
FAX
PHYSICIAN PRINTED NAME SPECIALTY PHYSICIAN’S FEDERAL ID #
PHYSICIAN’S SIGNATURE PATIENT ACCOUNT #
Date
DATE STOPPED WORK DUE TO DISABILITY NAME OF EMPLOYER
DATE RETURNED TO WORK
_________ / ________ / ________
_________ / ________ / ________
PHONE
FAX
EMPLOYER ADDRESS
SIGNATURE/TITLE OF OFFICIAL REPRESENTATIVE
Date
/ /
ATTENDING PHYSICIAN STATEMENT: To be completed by the Attending Physician
EMPLOYER STATEMENT: To be completed by the Patient’s Employer
75-101 (8/13)
______/______/______
POLICYOWNER & PATIENT INFORMATION: To be completed by the Policyowner
SEND THIS COMPLETED FORM TO THE CLAIMS PROCESSING CENTER BY:
EMAIL: Claims@NTALife.com FAX: 1-855-51 CLAIM (25246) MAIL: P.O. Box 2369 Addison, TX 75001-2369
FUNCTIONAL LIMITATIONS (i.e. physical hinderances such as the inability to walk or stand for extended periods of time)
CURRENT TREATMENT PLAN
ADDITIONAL COMMENTS
DATE OF NEXT SCHEDULED OFFICE VISIT FOR THIS
CONDITION
______/______/______
Attending Physician and Employer Statement
IS THE EMPLOYEE OFF WORK DUE TO DISABILITY THAT AROSE FROM EMPLOYMENT-RELATED ACTIVITIES? IS THE EMPLOYEE SEEKING BENEFITS UNDER WORKER’S COMPENSATION OR A SIMILAR EMPLOYER
SPONSORED PLAN?
YES NO
YES NO
( ) -
( ) -
( ) -
( ) -
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