ATTENDING PHYSICIAN'S STATEMENT CLAIM - Mutual of Omaha 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the insured's name and date of birth in the designated fields. Ensure accuracy as this information is crucial for processing.
3. In the History section, provide details about when symptoms first appeared and any previous similar conditions. Use the checkboxes to indicate yes or no responses where applicable.
4. For the Diagnosis section, clearly state the primary and secondary diagnoses along with any subjective symptoms and objective findings. This may include attaching diagnostic test results.
5. Fill in all treatment dates, including office visits and hospital confinement if applicable. Provide the name and address of any hospitals involved.
6. Detail the nature of treatment provided, including medications or therapies prescribed.
7. Indicate whether the patient has been released to return to work, and if not, answer questions regarding their ability to work and expected recovery timelines.
8. Finally, ensure that you print your name, degree, contact information, sign, and date at the bottom of the form before submitting.

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