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This document is a physician's statement for the Planning for Healthy Babies program, assessing eligibility for family planning services and Interpregnancy Care.

How to fill out physicians statement - dch

How to fill out PHYSICIAN’S STATEMENT

1. Begin with the patient's basic information, including name, date of birth, and contact details.
2. Provide the date of the examination or evaluation.
3. Clearly state the purpose of the physician's statement.
4. Describe the patient's medical history relevant to the request.
5. Include details about any current medical conditions, diagnosis, and treatment plans.
6. If applicable, mention any medications the patient is currently taking.
7. State the physician's qualifications and their relationship to the patient.
8. Sign and date the statement, ensuring to include the physician's contact information.

Who needs PHYSICIAN’S STATEMENT?

1. Individuals applying for disability benefits.
2. Students requiring physical fitness assessments for school activities.
3. Patients needing to provide medical clearance for surgery or athletic participation.
4. Employees applying for medical leave or accommodations due to health issues.

People Also Ask about

Who might be asked to fill out a physician's statement?

It is filled out by medical providers and submitted to insurers when filing your long-term disability claim. Attending physician statements are typically in the form of a questionnaire and provide pertinent information used in reviewing your eligibility for benefits.

Who completes an attending physician's statement?

Completing and Obtaining an Attending Physician Statement Your primary care physician or OB-GYN are good choices for providers who can complete this document.

What is included in an attending physician statement?

A typical APS will contain history of any medical conditions and prognosis. The doctor will explain your medical history by noting how long you have been treated, what are the symptoms, and what other treatments you might have had.

How does attending physician statement work?

An attending physician statement (APS) is a report by a physician, hospital, or medical facility that has treated, or is currently treating, a person seeking insurance. In traditional underwriting, an APS is one of the most frequently ordered additional sources of medical background information.

What is an example of a physician's statement?

I authorize any licensed physician, medical provider, hospital, medical facility, HMO, pharmacy, government agency, including the Social Security Administration and Veterans Administration, insurance or reinsurance company, credit or consumer reporting agency, financial/educational institutions and any current or

Who fills out attending physician statement?

Generally, a practicing physician with an M.D., D.O. or PhD fills out the APS. If a non-physician provider (e.g., nurse practitioner, licensed physical therapist) is the most knowledgeable person to answer questions about your condition and care plan, insurance companies will consider these statements as well.

What is a physician's statement of permanent disability?

An Attending Physician Statement (APS) is a form questionnaire from the insurance company that your treating doctor must complete. The purpose of the APS is for your doctor to certify your inability to work.

Who completes an attending physician's statement in APS?

The Attending Physician Statement (APS) will be completed by your treating provider, and will give us medical information regarding your date of disability, the diagnosis, the return to work date and any follow-up treatment.

For pdfFiller’s FAQs

What is PHYSICIAN’S STATEMENT?

A Physician's Statement is a formal document completed by a medical professional that provides important health-related information about a patient, often required for insurance purposes or medical evaluations.

Who is required to file PHYSICIAN’S STATEMENT?

Generally, individuals who are applying for insurance benefits, disability assistance, or any situation requiring medical validation are required to file a Physician's Statement.

How to fill out PHYSICIAN’S STATEMENT?

To fill out a Physician's Statement, the medical professional should provide clear and accurate information regarding the patient's medical history, diagnosis, treatment, and any relevant test results, while ensuring the form is signed and dated.

What is the purpose of PHYSICIAN’S STATEMENT?

The purpose of a Physician's Statement is to verify a patient's medical condition and treatment for purposes such as insurance claims, disability benefits, or medical leave requests.

What information must be reported on PHYSICIAN’S STATEMENT?

The information that must be reported includes the patient's personal details, diagnosis, treatment plan, prognosis, and any pertinent medical history that supports the need for the statement.