MEDICAL CERTIFICATE
Doctor: your certificate will establish the validity of the claim. Please complete fully. Applicable to the insured
person whose condition was the cause of this claim
The fields marked with a symbol are only to be completed if the patient is the claimant, their
spouse, or their dependent child.
Patient’s Name:
Claim/Policy number:
2. Diagnosis / medical condition:
3. On what date did the patient first present to you or any other physician for symptoms of this condition? (physical or clinical)
5. If known, date diagnosis determined?
6. Does the patient take prescribed medication for this condition
Yes No
If yes, please provide details (if necessary attach list):
7. If condition is pregnancy complications, what was the expected date of delivery?
*Additional Comments or notes:
The insured is responsible for any fees charged for the completion of this medical
certificate. For any inquiries, please call our Claims Customer Service Department at
1-800-263-8944.
ATTENDING PHYSICIAN’S
STAMP OR ATTACH
LETTERHEAD OR
PRESCRIPTION PAD
ATTENDING PHYSICIANS CERTIFICATE
To be completed in full by the attending physician for all
clinic, office, out-patient and short duration emergency room
visits.
4. If seen in follow up, please provide and attach clinical notes for all follow up dates entered
below:
Follow up dates MM/DD/YY:
2.
3.
4.
Name of drug
Date First Prescribed
Date Altered
Signature of attending Phyisican:
Address:
City: Province:
Country:
Postal Code:
Telephone:
Fax:
1. Was this an emergency medical condition? Yes No
1.
Date:
click to sign
signature
click to edit
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