Pearl Carroll Disability Insurance Form

CSEA Member’s Disability Income Form

STATEMENT OF RECOVERY OR RETURN TO WORK

Please answer all questions on the Member Statement on your Disability Income claim form and complete the List of Providers who have treated you.

Name:

Residential Address:

Social Security No.: Policy G-11628

I recovered I returned to work on

Other:

Email Address:

CSEA MEMBER’S DISABILITY INCOME FORM

List of Providers

Names and addresses of First Provider Consulted and other Providers seen for treatment.

Physicians

Hospitals

Pharmacies

Occupation and Daily Activities

Please state your occupation:

Please fully describe all the duties of your occupation at the time you stopped working including the percentage of time spent on each activity:

What are your daily activities since disability began?

Are you receiving or will you be eligible to receive benefits from:

Workman’s Compensation? Yes No
Pension Plan? Yes No
Another Group Insurance Plan? Yes No
Individual Disability Income Policy? Yes No
Social Security Disability? Yes No

If “Yes” insert policy number, claim number and address of insurance company or organization providing such benefits and amount of payment.

Authorization for Release of Information

Release From:

Patient’s Signature

Email Address:

Medical Provider’s Statement

Patient’s Name: SSN #

Date of Birth:

Current Medical Condition(s)

Primary Diagnosis: ICD-9 CM Code:

Secondary Diagnosis: ICD-9 CM Code:

Date that symptoms first appeared or accident happened:

Date that patient first consulted you for this condition:

Date you last treated the patient:

Is this condition related to patient’s employment? Yes No

Was patient referred to you by another practitioner? Yes No

If Yes, provide name and address:

Objective Findings:

Has patient been hospitalized? Yes No

Nature of treatment currently being provided or planned:

Have you referred the patient to another practitioner? Yes No

In your opinion is the patient able to work at this time? Yes No

If No, when do you expect the patient will be able to perform some work?

Is there any type of job modification or accommodation that would enable the patient to work at this time? Yes No

Based on objective findings and your medical opinion:

The patient was totally disabled from through

The patient was partially disabled from through

List all current restrictions and limitations you have placed on the patient’s work and personal activities due to his or her medical condition:

Has the patient been released from your care? Yes No

Medical Provider’s Declaration and Signature