FREE DISABILITY FORM

THERE IS NO CHARGE FOR THE FOLLOWING FORM IF COMPLETED BY PATIENT. THE FORM MUST BE REVIEWED AND SIGNED BY THE PHYSICIAN AFTER THE PATIENT PORTION HAS BEEN COMPLETED.

Southern Orthopaedic Specialists

Disability Claim Report

Instructions for Completion of Form:

  1. Please PRINT all information clearly.
  2. To avoid delay, be certain all information given is exact.
  3. Attach your insurance company's form (be certain you have signed both forms) and return to our Insurance Dept.

PART A TO BE COMPLETED BY PATIENT

Name ______________________________________SS# ______________________

Last First MI Policy # ___________________________

Address ___________________________________________ Birthdate ______________________

___________________________________________ Employer ______________________

Phone (Home)_______________________ Occupation ______________________

(Work)_______________________

Nature of Disability Illness ________ Work Injury ________ Accident ________

Date Date Date

Dates of Total Disability From: ________ To: ________

Dates of Partial Disability From: ________ To: ________

Physician You First Consulted for This Condition ___________________________ ___________

Date

I authorize Southern Orthopaedic Specialists to Release to the Payor any Information Necessary in the Completion of This Form

______________________________________________________________________________________________ _______________

Patient Signature Date

PART B TO BE COMPLETED BY PHYSICIAN

 

 

Chart # _______________________ Account # ______________

Diagnosis/icd9 code & description

__________________________________________________________________________________________

Treatment Dates (last 3 Mos.) __________________________________________________________________________________________

If Return to Work Date is Unknown, _______ _______ _______ _______ _______

Estimate Condition Improvement 1-2 mos. 3-4 mos. 4-6 mos. Other Never

Current Restrictions/Limitations

____________________________________________________________________________________________________________________________________________________________________________________

Remarks

__________________________________________________________________________________________

To the Best of my knowledge,

_____ part A is correct

_____ part A is correct w/ the noted exceptions in part B

_____ I do not have sufficient information to verify the information given in Part A

________________________________________________________________________________ _______________

Physician Signature Date

2731 Napoleon Avenue, New Orleans, Louisiana 70115 Phone (504) 897-6351 Fax (504) 899-7317