I understand that this information will be used by Standard Life and Casualty Insurance Company and ManhattanLife Insurance and Annuity Company for the purpose of evaluating my claim for insurance benefits. I represent that the answers to the questions on page 3 are complete, true and correct to the best of my knowledge and belief. I understand that I or my authorized representative is entitled to receive a copy of the authorization upon request. Insured’s Signature:_ _________________________ Print Name:___________________________ Date:______________
Physician’s Health Certification
Policy Number
Patient’s Name
Patient’s Address
Date of Birth
Sex:
Physician’s Tax I.D. Number
o Male
o Female
ICD-9-CM Principal Diagnosis
Date
ICD-10-CM Other Pertinent Diagnosis
Date
Home Healthcare Services Certified:
From:_____________To:_____________
Nursing Care (RN/LPN/LVN) Chemotherapy Specialist Enterostomal Therapy Medical Social Services Occupational Therapy Physical Therapy Other (Specify):_ ___________________________________________________________________________ Home Health Care Aide Respiratory Therapy Speech Pathology Can the patient perform any of the following Activities of Daily Living (ADLs) without the assistance of another person? Yes No o o Bathing (getting in and out of the bathtub or shower, utilizing normal bathroom facilities that have been equipped with railings and steps) o o Dressing (tying shoes, buttoning buttons or clasps) o o Eating (consuming food or drink or utilizing utensils, appropriate for the patient’s physical condition and which are placed within reach) o o Toileting (maintaining adequate bathroom hygiene and toilet habits) o o Transferring to or from bed or chair I certify that the above statements are true and correct and are based on standard medical tests I have performed and that the above home health services were/are required during the period of certification. Certifying Physician’s Signature________________________________________ Date Signed_______________________ Important Information To prevent delays, please provide documentation from your healthcare provider to support this claim. If you have additional bills or medical documentation related to this diagnosis other than the documentation defined, please submit them for review. Failure to complete all sections may result in a delay in processing this claim. For information or to check claim status, call 1-800-672-4535. Continence (the ability to maintain control of bowel and bladder function, or when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene (including caring for catheter or colostomy bag)) Does the patient require continuous supervision & assistance due to a Cognitive Impairment? □ Yes □ No o o
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