Fillable Mental Health Attending Physicians Statement (The Hartford)

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Mental Health Attending Physicians Statement (The Hartford)

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  • 61 check-boxes
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Mental Health Attending Physician’s Statement
TO BE COMPLETED BY THE PROVIDER
(The patient is financially responsible for this form)
Please fax the completed form to:
Fax Number: 833-357-5153
The Hartford
P.O. Box 14869
Lexington, KY 40512-4869
Email: GBInformationUpload@thehartford.com
Patient Last Name:
___________________________
Patient First (or Preferred) Name:
____________________________
Date of Birth:
_ _ /_ _ /_ _ _ _
Claim ID Number:
____________________
Provider Name:
___________________________
Provider Specialty:
____________________________
Phone:
______________
Fax/Email:
____________________
Please provide all medical records regarding your treatment of the patient
for the impairment reported within this report form.
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
________________________________________
________________________________________
|_ |__||__|.|__||__||__||__|
|__||__||__|.|__||__||__||__|
_|
____________________________________________________________________
_ _ /_ _ /_ _ _ _
If Yes, as of what date?
MM DD YYYY
Are these issues causing disincentive to return to work with the current employer? Yes No
Diagnosis
Primary Condition
DS
M or ICD Code
Secondary Condition
DSM or ICD Code
Current Self-Reported Symptoms
________________________________________________________________________________________________
Cu
rrent Mental Status Examination
Examination Date
MM DD YYYY
Category Description
Appearance Well Groomed Disheveled If different than baseline, explain: __________________
Attitude Cooperative Guarded Suspicious Uncooperative Belligerent
Speech Normal Halted Pressured Slurred Incoherent
Thought Process Logical/Co
herent Tangential Circumstantial Flight of Ideas Perseveration
Mood WNL Depressed Anxious Irritable Euphoric
Affect Congruent Incongruent Blunted Flat Labile
Insight into Illness Absent Fair Good
Psychomotor
Activity
WNL Agitation Retardation
Reasoning and
Judgment
WNL Impaired
Atten
tion Intact Impaired Mild Moderate Sev
ere
Concentration Intact Impaired Mild Moderate Severe
Memory Intact Impaired Mild Moderate Severe
LC-7592-11
Page 1 of 4
07/2021
Mental Health Attending Physician’s Statement
TO BE COMPLETED BY THE PROVIDER
(The patient is financially responsible for this form)
Please fax the completed form to:
Fax Number: 833-357-5153
The Hartford
P.O. Box 14869
Lexington, KY 40512-4869
Email: GBInformationUpload@thehartford.com
Patient Last Name:
___________________________
Patient First (or Preferred) Name:
____________________________
Date of Birth:
_ _ /
_ _
/_
_ _ _
Claim ID Number:
____________________
Current Mental Status Examination (continued)
Please identify how attention, concentration and/or memory impairments are being measured.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Additional observed symptoms (clinical presentation, frequency)
___________________________________________
_________________________________________________________________________________________________
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?
_____________ _______________________________________________________________________
_________________________________________________________________________________________________
Activities of Daily Living – Please provide input on the patient’s current ability to perform the following:
The patient is currently capable of
performing:
Volunteer work
Attending school
Self-employed
_______
______
_
________________
__________________________________
__________________________________
__________________________________
__________________________________
_
_
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Less demanding job
No work in any capacity
Significant weight/appetite change Yes No Pou
nds gained
Pounds lost
Time period
Sleep distur
bances Yes No Describe
Socialization Yes No Describe
Household chores Yes No Describe __________________________
_______
_________________________________
Routine
shopping Yes No Describe
In your opinion, is the
patient
competent to endorse checks
, and
direct the user of proceeds thereof?
Yes
No Describe
Drivers or operates a vehicle Yes No Describe
Caring
for self/others Yes No
Ar
e the impa
irments impacting the patient’s overall global functioning? If so, please explain.
Additional comments on ability to complete daily activities: ________________________________________________
LC-7592-11
Page 2 of 4
07/2021
Mental Health Attending Physician’s Statement
TO BE COMPLETED BY THE PROVIDER
(The patient is financially responsible for this form)
Please fax the completed form to:
Fax Number: 833-357-5153
The Hartford
P.O. Box 14869
Lexington, KY 40512-4869
Email: GBInformationUpload@thehartford.com
Patient Last Name:
___________________________
Patient First (or Preferred) Name:
____________________________
Date of Birth:
_ _
/_
_
/_ _ _ _
Claim ID Number:
____________________
Functionality
Are you recommending the patient stop working due to their current symptoms?
_ _ /_ _ /_ _ _ _
Yes
No
_ _ /_ _ /_ _ _ _
_
_____________________________________________________________________________________________
_ _
/
_ _ /_ _ _ _
_
______
______
_
_ _ /_ _ /
_ _ _ _
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________________________
_
_ _ /_ _ /_ _ _ _
_ _ /_ _ /_ _ _ _
_ _ /_ _ /_ _ _ _
_ _ /_ _ /_ _ _ _
__________
_______________________________________________________________________
_ _ /_ _ /_ _ _ _
_ _ /_ _ /_ _ _ _
____________________________________________________ ( _ _ _ ) _ _ _ - _ _ _ _
If Yes, Begin Date:
MM DD YYYY
Are the symptoms of such severity to preclude the patient from social / occupational functioning? Yes No
If Yes, when did the symptoms become severe enough to preclude social / occupational
functioning?
MM DD YYYY
If Yes, what work activities are impaired and how? __________________________________________________
What is the return to work date you
have discussed with the patient?
MM DD YYYY
Full-time Part-time
If Part-time, please specify: Hours per day Days per week
What date will the patient be
able to increase to full time?
MM DD YYYY
If appropriate, provide examples of accommodations that would allow the patient to return to work:
What are the patient's current abilities? What type of work can the patient perform
?
Additional comments:
________________________________________________________________________________________________
Treatment
Date of onset of
disability
MM DD YYYY
Date you first treated the
patient for any condition
MM DD YYYY
Date of onset of
this condition
MM DD YYYY
Date y
ou first treated the
patient for this condition
MM DD YYYY
Frequency of
treatment
List of relevant treatment dates
Date of last office
visit
MM DD YYYY
Date of next office visit
MM DD YYYY
Has the patient been referred to any other mental health providers/physicians? Yes No
If Yes, please provide the following information:
Provider Name Phone:
Provider Address _______________________________________________________________________________
Are you coordinating care with this provider? Yes No
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including underwriting companies Hartford Life and Accident Insurance Company and Hartford Fire
Insurance Company. Home Office is Hartford, CT. The Hartford is the administrator for certain group benefits business written by Aetna Life Insurance Company and Talcott
Resolution Life Insurance Company (formerly known as Hartford Life Insurance Company). The Hartford also provides administrative and claim services for employer leave of
absence programs and self-funded disability benefit plans.
LC-7592-11
Page 3 of 4
07/2021
Mental Health Attending Physician’s Statement
TO BE COMPLETED BY THE PROVIDER
(The patient is financially responsible for this form)
Please fax the completed form to:
Fax Number: 833-357-5153
The Hartford
P.O. Box 14869
Lexington, KY 40512-4869
Email: GBInformationUpload@thehartford.com
Patient Last Name:
___________________________
Patient First (or Preferred) Name:
____________________________
Date of Birth:
_ _
/
_ _
/
_ _ _ _
Claim ID Number:
____________________
Treatment (continued)
Was the 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:
( _
_ _
)
_ _ _
-
_ _ _ _
Admission date _ _
/_ _ /_ _ _ _
MM DD YYYY
Discharge date _ _
/_
_
/
_ _ _ _
MM
DD YYYY
Reason for inpatient admission
_________________________________
Partial Hospital/Day Treatment/IOP
Hospital/Facility Name ________________________________________________
Phone:
( _ _ _ )
_ _ _
-
_ _ _ _
Admission date
_ _ /_ _ /
_ _ _ _
MM
DD YYYY
Discharge date
_ _ /_ _ /_ _ _ _
MM
DD YYYY
Days per week
________
Hours per day
________
Residential
Hospital/Facility Name ________________________________________________ Phone:
( _ _ _ ) _ _ _ - _
_ _ _
Admission date
_ _ /_ _ /
_ _ _ _
MM
DD YYYY
Discharge date
_ _ /_ _ /
_ _ _ _
MM
DD YYYY
Days per week ________
Hours per day
________
Medication (dose, change, date of change)
_____________________________________________________________
_________________________________________________________________________________________________
_
________________________________________________________________________________________________
Response to medication (including any side effects)
______________________________________________________
_________________________________________________________________________________________________
Status (please check one)
In remission Improved
Unchanged
Retrogressed
Please provide a description of the most significant recent improvement and / or decompensation
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Provider Information
Provider Name: ____________________________________________
_____________________ ______________
____________________________________________
____________________________________________
License Number: _________________
( ) _ _ _ - _ _ _ _
( _ _ _ ) _ _ _ - _ _ _ _
____________________________________________
( _ _ _ )
_ _ _
- _ _ _ _
______________________________________________________________ _ _ /_ _ /_ _ _ _
Specialty: Degree: Phone: _ _ _
Address: Fax:
Email:
Office Con
tact: Contact Phone:
Provider Signature: Date:
MM DD YYYY
LC-7592-11
Page 4 of 4
07/2021
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Mental Health Attending Physicians Statement (The Hartford)

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Completed 15 February 2022

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