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Kaiser attending physician statement

Attending physician statement example 2026

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The document is an Income Protection Claim form that requires information from the attending physician regarding a patient's condition, including details about normal or complicated pregnancy, diagnosis, treatment, and work-related restrictions. It includes sections for patient identification, employer information, medical history, and physician's signature, along with a fraud notice.

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Click ‘Get Form’ to open the attending physician statement in the editor.
Begin by entering the patient's name, home telephone number, date of birth, and social security number in the designated fields.
Fill in the employer's name and telephone number. For Costco employees, you can pre-fill this information.
If the claim is related to normal pregnancy, complete the Normal Pregnancy section; otherwise, proceed to All Other Conditions.
In the Normal Pregnancy section, provide details such as expected delivery date and dates of hospitalization. Indicate if the patient has been released to work.
For All Other Conditions, enter diagnosis details including ICD9 codes and treatment nature. Specify any restrictions or limitations for the patient.
Complete the signature block at the bottom of the form with your name, degree, medical specialty, and contact information before submitting.

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What is the attending physician statement letter?

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 would an attending physicians statement be appropriate for?

Attending Physicians Statement in Health Insurance Its primary purpose is to assist in the underwriting process, which involves evaluating the risk of insuring an applicant. Among the options provided, the most appropriate response is: At the request of the insurer to assist in the underwriting decision.

What does an Attending Physician Statement include?

An attending physician statement is a form your physician must fill out. It comes in the form of a questionnaire. It will ask questions about your conditions and symptoms and how they impact your ability to work. You may come across other names for this form, such as a functional report.

Who completes an attending physicians statement?

This statement, filled out by your attending physician, provides the disability insurance company with vital data to assess the validity of your disability claim. The APS can influence the decision-making process significantly, making it crucial to ensure it is accurately and thoroughly completed.

Who might be asked to fill out a physicians statement?

In order to be effective, an Attending Physician Statement must be completed by a doctor who knows you in person your insurer or agency will reach out to get information from a physician who has either treated you in the past or is currently providing treatment.

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What is the purpose of an attending physician statement?

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.