Physician Statement_15692_0414
PATIENT’S DIAGNOSIS
Diagnosis ICD Code On what date did the symptoms/injury rst appear? Did you perform an actual examination? Date of initial examination:
Please list all dates of examination and treatment Is this condition a complication of an underlying condition? If yes, please explain
If the patient is our insured traveler, on what date
did he/she become medically unable to travel?
How long will the patient be disabled? Did you advise that the trip should be cancelled or interrupted due to the patient’s medical condition?
If yes, what date?
Please provide details explaining the patient’s diagnosis. If you advised the patient that the trip should be cancelled or interrupted due to this medical condition, please explain the basis for your travel recom-
mendation. If this is due to an injury, please give details of the injury.
BY MY SIGNATURE AND STAMP BELOW, I HEREBY CERTIFY THAT THE ABOVE IS TRUE AND CORRECT.
Physician Signature Tax ID Date
Please provide details surrounding your prior treatment of this patient.
Print Name
Are you the patient’s primary care
physician?
If NO, primary care physicians name Phone Was the patient referred to you by the
primary care physician?
YES NO YES NO
YES NO DATE_______________________
YES NO
YES NO
City State Zip Code Phone Fax
SECTION 4: PHYSICIAN’S STATEMENT (TO BE COMPLETED BY PHYSICIAN ONLY)
PATIENT INFORMATION
Patient’s Name Date of Birth
Physician Information
Examining Physician’s Name Specialty Street Address
