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The form allows for submission of either a new claim or an existing claim, ensuring clarity in the claims process.
Claimants must provide itemized bills for covered expenses and documentation confirming their disability status to support their claims.
The attending physician is required to complete Side 2 of the form, providing necessary medical information related to the claim.
Total disability is defined as an absolute physical incapacity to perform any work due to sickness or injury, which must be documented by a physician.
Dates of disability reported by both the member and the doctor must align; discrepancies may lead to delays in processing the claim.
Providing false or misleading information on this form can result in severe penalties, including imprisonment and fines.
By signing the form, members authorize healthcare providers and employers to share relevant health and employment information with PFIA for eligibility verification.
