Physician statement form 2026

1. Click ‘Get Form’ to open the physician statement form in the editor.
2. Begin by filling out the Primary Insured’s section, including their name, policy number, and insurance purchase date.
3. Next, move to the Patient Information section. Enter the patient's name, date of birth, street address, city, state, and zip code.
4. In the Physician Information section, provide your name, specialty, street address, city, phone number, fax number, state, and zip code.
5. Indicate whether you are the patient’s primary care physician and provide their contact information if applicable.
6. Complete the Diagnosis section by answering whether an examination was performed and providing details about the diagnosis and relevant dates.
7. If applicable, explain any recommendations regarding trip cancellation due to medical conditions.
8. Finally, sign and date the form before submitting it via email or fax as indicated at the bottom of the document.

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