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Sun Life Assurance Company of Canada (Cape Fear Community College)

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XGR/1642 LTD Claim Packet – Attending Physician Page 1 of 9
Claimant:
DOB:
Policy no.:
CC no:
Sun Life Assurance Company of Canada
Long-Term Disability Claim Packet – Attending Physician
Instructions for the Attending Physician
Please be sure to submit the
Attending Physician’s Statement directly to Sun Life Financial.
The Attending Phy
sician must:
Complete, sign and date the Attending Physician’s Statement
Submit the Attending Physician’s Statement directly to Sun Life Financial
M
ail or fax the completed claim form to:
Sun Life Assurance Compan
y of Canada
Group Long
-Term Disability Claims
P.O. Box 81830
Wellesley Hills, MA 02481
Fax:
781-304-5537
Failure to provide complete and accurate information could result in the need for additional
claims investigation which could delay the initial benefit payment.
919310
XGR/1642 LTD Claim Packet – Attending Physician Page 2 of 9
Claimant:
DOB:
Policy no.:
CC no:
Sun Life Assurance Company of Canada
Long-Term Disability Claim Packet – Attending Physician
Fraud Warnings
State law requires that we notify you of the following:
General f
raud 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 fraudule
nt insurance act, which is a crime and subjects
such person to criminal and civil penalties.
AK
: A person who knowingly and with intent to injure, defraud, or deceive an insurance
company files a claim containing false, incomplete, or misleading informatio
n may be
prosecuted under state law.
AL:
Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or who knowingly presents false information in an application for insurance is guilty of a
crime and may be subject to r
estitution fines or confinement in prison, or any combination
thereof.
AR, LA, MA, MN,
RI, TX, and WV: Any person who knowingly presents a false or fraudulent
claim for payment of a loss or benefit or knowingly presents false information in an applicat
ion
for insurance is guilty of a crime and may be subject to fines and confinement in prison.
AZ
: 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 pay
ment of a loss is subject to
criminal and civil penalties.
CA
: 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
a
nd may be subject to fines and confinement in state prison.
CO
: 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
def
rauding 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.
DC
: 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.
DE, ID, and IN
: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, files a statement of claim containing any false, incomplete or misleading information is
guilty of a felony.
FL
: 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.
KS
: 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 may be guilty of insurance fraud as determined by a court of law.
919310
XGR/1642 LTD Claim Packet – Attending Physician Page 3 of 9
Claimant:
DOB:
Policy no.:
CC no:
Fraud Warnings continued
KY
: 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 con
cerning any fact material thereto commits a fraudulent
insurance act, which is a crime.
MD:
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.
ME: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the compa
ny. Penalties include
imprisonment, fines and denial of insurance benefits.
NH
: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files
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.
NJ
: Any person who knowingly files a statement of claim containing any false or misleading
information is subject to criminal and civil penalties.
NM:
Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or k
nowingly presents false information in an application for insurance is guilty of a crime
and may be subject to
civil fines and criminal penalties.
OH
: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement is guilty
of insurance fraud.
OK
: WARNING: 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.
OR and VA
: Any person who, with intent to defraud or knowing that he is facilitating a fraud
against an insurer, submits an application or files a claim containing a false or deceptive
statement may have violated state law.
PR
: Any person who knowingly and with the intention of defrauding presents false information in
an insurance appl
ication, 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 ea
ch 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 e
stablished 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.
TN and WA:
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.
VT
: Any person who knowingly presents a false statement in an application for insurance may
be guilty of a criminal offense and subject to penalties under state law.
919310
XGR/1642 LTD Claim Packet – Attending Physician Page 4 of 9
Claimant:
DOB:
Policy no.:
CC no:
Sun Life Assurance Company of Canada
Long-Term Disability Claim Packet – Attending Physician
Attending Physician’s Statement – Physical conditions only
Group policy number
1 Patient Information
The patient is responsible for any costs associated with the completion of this form.
Name of Patient (first, middle initial, last)
M
F
Social Security number Date of birth (m/d/y)
Do you believe this patient is competent to endorse checks? ..............................................
Yes
No
2 Diagnosis and History
Provide general
information about
diagnosis and history
in this section. Then,
please elaborate in
section(s) 3 – 6
as appropriate.
Primary diagnosis
Secondary diagnosis
Objective findings/investigative testing (i.e., x-rays, EKGs, MRIs, laboratory data, etc.)
Subjective symptoms
Date symptoms first appeared or date
of accident
If injury is due to a motor vehicle accident, indicate in which
state the accident occurred.
Is condition due to injury/sickness arising out of patient’s employment? ....... Yes No Unknown
Names and addresses of other treating physicians (if applicable)
If pregnancy, please provide the following information:
Expected delivery date:
Actual delivery date:
C-Section?
Yes
No
3 Treatment
Include in description any surgery, therapeutic modalities, psychological intervention and
medications prescribed.
Date of first visit Date of most recent visit Blood pressure
Frequency of treatment .............. Weekly Monthly Other (please specify: )
Description of Treatment
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XGR/1642 LTD Claim Packet – Attending Physician Page 5 of 9
Claimant:
DOB:
Policy no.:
CC no:
4 Progress
Patient:
Unchanged Improved Retrogressed Ambulatory Bed confined
If retrogressed, please explain:
Has patient been hospital confined? ........... Yes No From: To:
If yes, provide name of hospital, address and dates of confinement
5 Restrictions and Limitations
Restrictions: What activities your patient should not do
Limitations: What activities your patient cannot do
Patient’s dominant hand is: Left Right
Patient is able to use hand for repetitive actions such as:
Simple Grasping Firm Grasping Fine Manipulation Key Boarding
Left Yes No Yes No Yes No Yes No
Right Yes No Yes No Yes No Yes No
In a typical work day, patient is able to: (This is not considered an FCE)
Continuously Frequently Occasionally Negligible
Walk
Sit
Stand
Bend
Squat
Climb
Twist
Push
Pull
Balance
Kneel
Crawl
Reach above
shoulder level
Lift
lbs.
lbs.
lbs.
lbs.
Carry
lbs.
lbs.
lbs.
lbs.
Is the patient able to drive during a typical work day?
............................................................. Yes No
919310
XGR/1642 LTD Claim Packet – Attending Physician Page 6 of 9
Claimant:
DOB:
Policy no.:
CC no:
5 Restrictions and Limitations continued
Physical Impairment
No limitation of functional capacity – (no restrictions)
Medium capacity – (lifting, carrying, pushing, pulling 20-50 lbs. occasionally; 10-25 lbs.
frequently; or up to 10 lbs. constantly)
Light capacity – (lifting, carrying, pushing, pulling 20 lbs. occasionally; 10 lbs. frequently; or
negligible amount constantly. Can include walking and/or standing frequently even if the weight is
negligible. Can include pushing or pulling of arm or leg controls.)
Sedentary capacity – (lifting, carrying, pushing, pulling 10 lbs. occasionally. Mostly sitting, may
involve standing or walking for brief periods of time.)
Comments (please explain):
Cardiac
(if applicable) - Functional capacity (American Heart Association)
No limitation Marked limitation
Slight limitation Complete limitation
6 Prognosis
How long will those limitations apply? (estimated)
6-8 weeks 8-12 weeks 12-26 weeks
Expected recovery date: _________
No recovery expected
7 Remarks
Please use this space for any additional comments.
If needed, what would be a convenient day/time of day for our benefits administrator or medical doctor
consultant to call you?
________________________________________________
8 Certification and Signature
Remember to provide
your full address,
phone number, and
Tax ID number.
A stamp or signature
of a person other
than the examining
physician,
physician’s assistant,
or nurse practitioner
is not acceptable.
I certify that the above statements are true and complete. I have read or had read to me the fraud
warning for my state.
Name of Attending Physician (first, middle initial, last)
Degree/Specialty
Street address
City
State
Zip Code
Tax ID number
Telephone number
Fax number
Attending Physician Signature
X
Date
Please be sure to return the completed Attending Physician’s Statement to:
Sun Life Assurance Company of Canada
Group Long
-Term Disability Claims
P.O. Box 81830
Wellesley Hills, MA
02481
Fax: 781
-304-5537
919310
XGR/1642 LTD Claim Packet – Attending Physician Page 7 of 9
Claimant:
DOB:
Policy no.:
CC no:
Sun Life Assurance Company of Canada
Long-Term Disability Claim Packet – Attending Physician
Attending Physician’s Statement – Behavioral health conditions only
Group policy number
1 Patient Information
The patient is responsible for any expense involved in the completion of this form. Please be sure
to respond to all items as specifically and completely as possible.
Please print clearly
Name of patient (first, middle initial, last)
M
F
Claimant control number
Social Security number
Date of birth (m/d/y)
Use current DSM.
2 Treatment Information
Date of first signs of illness
Date of first exam
Date of recent exam
Frequency of visits: Weekly Monthly Other (specify):
Has the patient ever had a psychiatric hospitalization, partial hospitalization, intensive outpatient
treatment?.......................................................................................................................... Yes No
Facility name Address Admission date Discharge date
Describe the patient’s initial reason for seeking treatment. Specify how and when the symptoms
first appeared and the progression of symptoms to current level.
Describe the patient’s current symptoms.
Have any quantitative evaluations of functional impairment been performed?
.......
Yes No
If yes, please list the psychological/neuropsychological testing performed and provide copies of
the test and the raw data.
If no, have any evaluations been planned? Specify scheduled dates, if any.
Describe the patient’s mental status.
Describe if/how the patient’s psychiatric condition is limiting the patient’s functional capacity.
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919310
XGR/1642 LTD Claim Packet – Attending Physician Page 8 of 9
Claimant:
DOB:
Policy no.:
CC no:
2 Treatment Information continued
Degree of impairment
0 = None – no impairment in this area
1 = Slight – suspected impairment of slight importance that does not affect functional ability
2 = Moderate – impairment that affects but does not preclude ability to function
3 = Severe – extreme impairment of ability to function
Comments (please explain):
Activity
Degree of impairment
Comments
Interpersonal relations
0
1 2 3
Daily activities (e.g. hygiene,
shopping, household chores,
caring for children)
0 1 2 3
Occupational/social (e.g., respond
appropriately to supervision,
supervise or
manage others)
0 1 2 3
Ability to think/reason
0
1 2 3
Understand and carry out
instructions
0 1 2 3
Sustain work performance
0 1 2 3
Attention span
0 1 2 3
Concentration
0
1 2 3
Past/present memory disturbance
0 1 2 3
Do you feel that the patient’s condition is prec
ipitated by a situation at their place of employment?
Yes No
If yes, please provide the details of the employment situation.
Are the patient’s problems
related to alcohol or drug abuse?
.................................
Yes
No
If yes, please specify, including onset, severity, types of drugs used, and prior treatment.
Is return-to-work part of your treatment plan?........................................................................ Yes
No
Please provide estimated return-to-work date __________ Part-time Full-time
Specify any other factors that may have precipitated and could influence recovery and return to
work. (e.g. family history, effects of physical illness, psychological history, educational history,
inability to tolerate medications, legal or licensing difficulties, financial difficulties, occupational
issues, etc.)
919310
Sun Life Assurance Company of Canada is a member of the Sun Life Financial group of companies.
© 2018 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved.
Sun Life Financial and the globe symbol are registered trademarks of Sun Life Assurance Company of Canada.
XGR/1642 LTD Claim Packet – Attending Physician Page 9 of 9 1/18
Claimant:
DOB:
Policy no.:
CC no:
2 Treatment Information continued
Has this patient ever suffered from symptoms of the same, similar or other mental or emotional disorder
in the past? ............................................................................................ Yes No Don’t know
If yes, please provide details, including previous treatment, names and addresses of providers,
and patient’s response to treatment.
Please provide a list of medication.
Medication
Dosage
Date
Started
Response
Date
Discontinued
Is the patient capable of managing his/her financial affairs? .............................................. Yes No
If yes, do you believe this patient is competent to endorse checks? ................................. Yes No
3 Certification and Signature
Remember to
provide your full
address and Tax ID
number.
A stamp or signature
of a person other
than the examining
physician is not
acceptable.
Attached is the claimant’s signed authorization form for release of records. Please attach copies of all
treatment notes, including initial evaluation, with the submission of this statement.
You may be contacted to further discuss or clarify the claimant’s psychiatric information.
I certify that the above statements are true and complete.
I have read or had read to me the fraud warning
for my state.
Name of Attending Physician (first, middle initial, last)
Degree/Specialty
Street address
City
State
Zip Code
Tax ID number
Telephone number
Fax number
Attending Physician Signature
X
Date
Please be sure to return the completed Attending Physician’s Statement to:
Sun Life Assurance Company of Canada
Group Long
-Term Disability Claims
P.O. Box 81830
Wellesley Hills, MA 024
81
Fa
x: 781-304-5537
919310
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Completed 1 October 2020

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