Fillable Short Term Disability Claim Form Physicians Statement (Lincoln Financial Benefits)

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Short Term Disability Claim Form Physicians Statement (Lincoln Financial Benefits)

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The Short Term Disability Claim Form Physicians Statement (Lincoln Financial Benefits) form is 2 pages long and contains:

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  • 5 check-boxes
  • 112 other fields

Country of origin: US
File type: PDF

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Page 1 of 4
GLC11738STD-C 1/18
1. Patient Information
Full Name (First)
(M.I.)
(Last Name)
Height Weight Blood Pressure
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its afliates.
Short Term Disability Claim Form Physician’s Statement
2. Diagnosis
Primary ICD diagnostic Code (Required) Primary ICD diagnosis Description
Secondary ICD Diagnosis Code
Secondary ICD Diagnosis Description
Social Security Number
Employer Name
Symptoms
Objective Findings (Include copies of any x-rays, laboratory data, EKG’s, MRI’
s, scans and any clinical ndings)
Pregnancy
/ / / / / /
h Vaginal h C-Section
First Treated
Estimated Delivery Date of Delivery
Claim Submission Part 1 of 2
The Lincoln National Life Insurance Company is not responsible for charges incurred due to completion of this form. The patient is responsible for any charges associated with form completion.
(Please see FRAUD NOTICES attached)
Date of:
The Lincoln National Life Insurance Company
PO Box 2609, Omaha, NE 68103-2609
Toll Free (800) 423-2765 Fax (877) 843-3950
www.LincolnFinancial.com
disabilityclaims@lfg.com
3. Disability Circumstances - Check if applicable
h Illness h Injury h Work Related
If work related or injury, summarize circumstances
/ / / / / /
Symptoms rst Appeared
Reduced Ability to work
Advised to stop work
/ / / / / /
Initial Treatment
Most Recent Treatment
Next Treatment
Dates hospital conned:
/ / / /
to
Page 2 of 4
GLC11738STD-C 1/18
Indicate frequency per day the listed activities below can be used performed using:
N= Never 0% O= Occasionally <33% F= Frequently 34%-66% C= Continuously 67% - 100%
Lifting/Carrying Reaching
1-5 lbs.
_____ Standing ____ Crouching _____ Overhead ______
6-10 lbs. _____ Walking ____ Crawling _____ Desk Level ______
11-25 lbs. _____ Sitting ____ Grasping _____ Below Waist ______
26-50 lbs. _____ Balancing ____ Climbing _____
51-100 lbs. _____ Stooping ____ Pushing _____
100 + lbs. _____ Kneeling ____ Pulling _____
Fingering ____ Bending _____
What job modications would allow the patient to return to work?
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its afliates.
Short Term Disability Claim Form Physician’s Statement
4. Limitations and Restrictions
Restrictions (what the patient SHOULD NOT do)
Limitations (what the patient CANNOT do)
Describe ongoing treatment frequency
Patient able to return to work
Full-Time on:
/ / / /
If a specic date is unavailable, please provide a
date range you expect a fundamental or marked
change.
Phone Number
Fax Number
/ /
Signature
Date
to
Describe current and recommended treatment plans including any completed or
future surgeries. (Include dates)
6. Prognosis
Describe the patients prognosis for recovery
5. Treatment
7. Physician’s Information
Name
Street Address
City
State Zip Code
Activities of Daily Living
I
f patient cannot complete these activities of Daily living
indicate, when they were rst unable to do so. (M/D/Y)
Continence / /
Dressing / /
Transferring / /
Bathing / /
Toileting / /
Eating / /
Date patient experienced loss of
Cognitive Functioning: / /
Claim Submission Part 2 of 2
(Please see FRAUD NOTICES attached)
The Lincoln National Life Insurance Company is not responsible for charges incurred due to completion of this form. The patient is responsible for any charges associated with form completion.
The Lincoln National Life Insurance Company
PO Box 2609, Omaha, NE 68103-2609
Toll Free (800) 423-2765 Fax (877) 843-3950
www.LincolnFinancial.com
disabilityclaims@lfg.com
Page 3 of 4
GLC11738STD-C 1/18
FRAUD NOTICES. For your protection, certain states require that the following notices appear on this form.
Alabama. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet
or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution nes or connement in prison, or any combination thereof.
Alaska. A person who knowingly and with intent to injure, defraud, or deceive an insurance company les a
claim containing false, incomplete or misleading information may be prosecuted under state law.
Arizona. For your protection Arizona law requires the following statement to appear on this form. Any
person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and
civil penalties.
Arkansas, Louisiana, Rhode Island and West Virginia. Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benet or knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to nes and connement in prison.
California. For your protection California law requires the following to appear on this form: 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 nes and connement in state prison.
Colorado. 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, nes, 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 a settlement or award payable from insurance proceeds shall be reported to the Colorado
Division of Insurance within the Department of Regulatory Agencies.
Delaware. Any person who knowingly, and with intent to injure, defraud or deceive any insurer, les a
statement of claim containing any false, incomplete or misleading information is guilty of a felony.
District of Columbia. 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 nes. In addition, an
insurer may deny insurance benets if false information materially related to a claim was provided by the
applicant.
Florida. Any person who knowingly and with intent to injure, defraud, or deceive any insurer les a statement of claim
or application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Idaho. Any person who knowingly, and with intent to defraud or deceive any insurance company, les a
statement or claim containing any false, incomplete or misleading information is guilty of a felony.
Indiana. A person who knowingly and with intent to defraud an insurer les a statement of claim containing
any false, incomplete, or misleading information commits a felony.
Kentucky. Any person who knowingly and with intent to defraud any insurance company or other person les
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.
Maine. It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for
the purpose of defrauding the company. Penalties may include imprisonment, nes or a denial of insurance benets.
Maryland. Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss
or benet or who knowingly or willfully presents false information in an application for insurance is guilty of
a crime and may be subject to nes and connement in prison.
Minnesota. A person who les a claim with intent to defraud or helps commit a fraud against an insurer is
guilty of a crime.
Page 4 of 4
GLC11738STD-C 1/18
New Hampshire. Any person who, with a purpose to injure, defraud or deceive any insurance company, les
a statement of claim containing any false, incomplete or misleading information is subject to prosecution
and punishment for insurance fraud, as provided in RSA 638:20.
New Jersey. Any person who knowingly les a statement of claim containing any false or misleading
information is subject to criminal and civil penalties.
New Mexico. Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benet or knowingly presents false information in an application for insurance is guilty of a crime and may
be subject to civil nes and criminal penalties.
New York. Any person who knowingly and with intent to defraud any insurance company or other person les
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 subject to a civil penalty not to exceed ve thousand dollars and the stated value
of the claim for each such violation.
Ohio. Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer,
submits an application or les a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma. Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any
claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is
guilty of a felony.
Oregon. Any person who knowingly and with intent to defraud any insurance company or other person: (1)
les 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, may have committed a
fraudulent insurance act.
Pennsylvania. Any person who knowingly and with intent to defraud any insurance company or other
person les 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.
Puerto Rico. 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 benet, 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 ne of not less than ve thousand
dollars ($5,000) and not more than ten thousand dollars ($10,000), or a xed 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 ve (5) years, if extenuating circumstances are present, it may be
reduced to a minimum of two (2) years.
Tennessee, Virginia, and Washington. 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, nes and denial of insurance benets.
Texas. 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 nes and connement in state prison.
FOR ALL OTHER STATES EXCLUDING CONNECTICUT AND KANSAS. A person may be committing
insurance fraud, if he or she submits an application or claim containing a false or deceptive statement with
intent to defraud (or knowing that he or she is helping to defraud) an insurance company.
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Short Term Disability Claim Form Physicians Statement (Lincoln Financial Benefits)

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Completed 25 August 2021

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