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Attending physician statement example 2026
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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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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2008 | 4.7 Satisfied (30 Votes) |
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attending physician statement
ATTENDING PHYSICIANS STATEMENT. This form is to be completed without expense to Liberty Mutual and returned along with your original claim for benefits or.Read more
If the physician is Board- certified in a particular specialty, please indicate such and provide the specific specialty in Box 17. Please send the completedRead more