Fillable Physicians Statement NEW YORK FRAUD WARNING: Any person (Cigna Medicare Providers)

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Physicians Statement NEW YORK FRAUD WARNING: Any person (Cigna Medicare Providers)

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GB-608066 Rev. 03/2021
Please complete all relevant sections as thoroughly as possible and include medical documentation to support your findings.
3.
PHYSICIAN’S STATEMENT OF DISABILITY (PLEASE PRINT)
SOCIAL SECURITY NUMBER
GROUP POLICY NUMBERSTATE
EMPLOYER NAME
EDC:
ZIP CODE
NAME
Dosage
TELEPHONE
ADDRESS
OCCUPATION
(d)
CITY
(c) Name and Address of Hospital
(c) Objective findings (Please attach copies of current X-rays, EKG’s, Laboratory Data and any clinical findings as applicable.)
THIS SECTION IS TO BE COMPLETED BY THE PATIENT/INSURED
(f) If pregnancy please indicate:
(d) Are symptoms consistent with the clinical findings?
(a) Diagnosis (Include ICD or DSM Code)
(e) Is illness work related?
(b) Subjective symptoms
(b) Date patient first unable to work due to this accident/illness: (Month/ Day/Year)
Actual Delivery:
THE REMAINING SECTIONS OF THIS FORM ARE TO BE COMPLETED BY YOUR PHYSICIAN(S)
LMP:
1. DIAGNOSIS (Including any complications)
Medications
(d) Date of last visit: (Month/ Day/Year)
Type
(c) List frequency & date(s) patient was examined for this accident/illness:
NATURE OF TREATMENT (Including Surgery & Medications prescribed, if any)
(a) Date patient first visited you for this accident/illness:
(Month/ Day/Year)
DATE OF BIRTH
2. DATES OF TREATMENT
Type of Surgery:
THROUGH
(a) Hospitalization on: (Month/ Day/Year)
(b) Surgery on: (Month/ Day/Year)
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by the GINA Title II from requesting or
requiring genetic information of employees or their family members. In order to comply with this law, we are asking that you not provide any genetic
information when responding to this request for medical information. "Genetic Information," as defined by GINA, includes an individual’s family
medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or
received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an
individual or family member receiving assistive reproductive services.
No, explainYes
No
Yes
Physician’s Statement
Page 1 of 3
NEW YORK FRAUD WARNING: 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 shall also be subject to a civil penalty not to exceed $5000 and the stated
value of the claim for each such violation.
For residents of the following states, please see the last page of this form: California, Colorado, District of Columbia, Florida, Kansas, Kentucky,
Louisiana, Maryland, Minnesota, New Jersey, Oregon, Pennsylvania, Puerto Rico, Rhode Island, Tennessee, Texas, Virginia or Washington.
(Month/ Day/Year)
© 2021, New York Life Insurance Company, New York, NY. All rights reserved. NEW YORK LIFE and the New York Life box logo are registered trademarks of New York Life
Insurance Company. Life Insurance Company of North America and New York Life Group Insurance Company of NY are subsidiaries of New York Life Insurance Company.
CLEAR FORM
GB-608066 Rev. 03/2021
Baseline:
5. MENTAL IMPAIRMENT / IF APPLICABLE - Please complete the following (incomplete information will delay claim processing):
6.
RETURN TO WORK STATUS
7. REMARKS
0 hours
Climb
Balance
Stoop
Kneel
Crouch
Crawl
Reach
Walk
Sit
Stand
Cardiac - If applicable
up to 5.5 hours up to 2.5 hours greater than 5.5 hours
(American Heart Association)
Class 1 - No Limitation
Class 2 - Slight Limitation
Class 3 - Marked Limitation
Class 4 - Complete Limitation
Blood Pressure (last visit)
Lift Carry Push Pull
Please indicate the maximum level of ability (sedentary, light, medium, heavy) of your patient to:
Sedentary = 10 lbs. maximum, walking occasionally. Light = 20 lbs. maximum, 10 lbs. frequently
Medium = 50 lbs. maximum, 25 lbs. frequently, up to 10 lbs. constantly. Heavy - 100 lbs. maximum, 50 lbs. frequently, 20 lbs. constantly.
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V: Current GAF:
4. PHYSICAL LIMITATIONS / IF APPLICABLE: In an 8-hour work day is your patient able to:
When was patient able to go to work?
Patient’s Regular Occupation
Mo.
Physician Signature: Date:
Physician Name (Please Print):
Telephone Number:
Address: (Street, City, State, Zip Code)
Federal Tax ID #:
Degree & Specialty:
Day
Yr.
/ /
Full-time
Part-time
Mo. Day Yr.
/
/
Any Other Occupation
Additional Comments:
Highest GAF in past year:
Part-time
Full-time
Page 2 of 3
GB-608066 Rev. 03/2021
Page 3 of 3
Minnesota Residents: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a
crime.
District of Columbia Residents: 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.
IMPORTANT CLAIM NOTICE
Colorado Residents: 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 settlement or award payable from insurance proceeds shall be reported to
the Colorado division of insurance within the department of regulatory agencies.
Oregon Residents: Any person who includes any false or misleading information on an application for an insurance policy, may
be guilty of fraud and may be subject to civil or criminal penalties if intentional and material to the risk assumed.
Virginia Residents: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer,
submits application or files a claim containing a false or deceptive statement may have violated state law.
Rhode Island Residents: 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.
Texas Residents: 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.
New Jersey Residents: Any person who knowingly files a statement of claim containing any false or misleading information is
subject to criminal and civil penalties.
Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files 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.
Florida Residents: 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.
Pennsylvania Residents: 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.
Tennessee Residents: 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.
California Residents: 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.
Maryland Residents: Any person who knowingly or willfully 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.
Kansas Residents: Any person who knowingly and with intent to defraud any insurance company or other person (1) files an
application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of
misleading, information concerning any material fact thereto, may be guilty of insurance fraud determined by a court of law.
Louisiana Residents: 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.
Washington Residents: 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.
Puerto Rico Residents: Caution: 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 by 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.
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Physicians Statement NEW YORK FRAUD WARNING: Any person (Cigna Medicare Providers)

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Completed 14 January 2022

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