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    Medical Opinion

    Uploaded by

    efmezahn
    This document is a medical claim form for an insurance policy. It requests information about the policyholder, their medical history and treatment for their current condition. The form collects details about the policyholder including name, contact information, date of birth, employer and secondary insurance. It asks the treating physician to provide information such as how long they have been treating the patient, the diagnosis, test results, treatment plan and costs. The physician is asked to describe the patient's full medical history relating to their current condition including prior treatments. They must also provide the anticipated length of hospital stay if required and approval for other physicians' assistance or a second medical opinion.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Medical Opinion

    Uploaded by

    efmezahn
    18 views1 page
    This document is a medical claim form for an insurance policy. It requests information about the policyholder, their medical history and treatment for their current condition. The form collects details about the policyholder including name, contact information, date of birth, employer and secondary insurance. It asks the treating physician to provide information such as how long they have been treating the patient, the diagnosis, test results, treatment plan and costs. The physician is asked to describe the patient's full medical history relating to their current condition including prior treatments. They must also provide the anticipated length of hospital stay if required and approval for other physicians' assistance or a second medical opinion.

    Original Description:

    Opinión médica

    Original Title

    medical-opinion

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    © © All Rights Reserved

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    This document is a medical claim form for an insurance policy. It requests information about the policyholder, their medical history and treatment for their current condition. The form collects details about the policyholder including name, contact information, date of birth, employer and secondary insurance. It asks the treating physician to provide information such as how long they have been treating the patient, the diagnosis, test results, treatment plan and costs. The physician is asked to describe the patient's full medical history relating to their current condition including prior treatments. They must also provide the anticipated length of hospital stay if required and approval for other physicians' assistance or a second medical opinion.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    18 views1 page

    Medical Opinion

    Uploaded by

    efmezahn
    This document is a medical claim form for an insurance policy. It requests information about the policyholder, their medical history and treatment for their current condition. The form collects details about the policyholder including name, contact information, date of birth, employer and secondary insurance. It asks the treating physician to provide information such as how long they have been treating the patient, the diagnosis, test results, treatment plan and costs. The physician is asked to describe the patient's full medical history relating to their current condition including prior treatments. They must also provide the anticipated length of hospital stay if required and approval for other physicians' assistance or a second medical opinion.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    MEDICAL OPINION | CLAIM FORM

    Seguros
    For 24/7 service please dial * +504-2276-3960 (Service provided in Spanish) Código: SPN-F.GSP-09
    Policy No. Certificate No. Amount: BPM:
    To be filled by insurance company
    I. General Information
    1) Policyholder Spouse Child of primary subscriber
    2) Full name Female Male
    3) Phone number Email

    4) DOB Employer Id.#

    5) Do you or your spouse have a secondary insurance? Yes No Name the insurance company
    6) Since when have you been insured?
    II. Medical history / Outpatient consultation (To be filled by treating physician only)

    1) Since when have you been treating the patient? Month Day Year

    2) Cause of Condition:
    Positive Test Result Date
    Workplace accident Other accidents Common Disease Pregnancy
    Car Accident Occupational Disease HIV
    Month Day Year
    3) Describe full diagnosis, injuries found, medical complications and treatments received: (Use ICD-10 Codes)

    4) Initial diagnosis date or date accident occurred? Month Day Year

    5) Has the patient previously been treated for the same or a diferent condition? Yes No
    If Yes, date of treatment Treating physician

    6) Tests, Procedure, Treatment or/and Surgery needed

    Scheduled to happen on: Month Day Year


    7) Medical Institution where medical treatment will be provided

    Length of hospital stay required (do not use numbers) Days


    8) Total Procedure Fee (Please include all pre and post operatory related fees) $
    9) CPT Code Percentage Percentage Amount $
    CPT Code Percentage Percentage Amount $
    CPT Code Percentage Percentage Amount $
    CPT Code Percentage Percentage Amount $

    Can the treatment be done outpatient? Yes No Do you require assistance? Yes No
    Do you require an anesthesiologist? Yes No Do you require another physician's assistance? Yes No

    If yes, briefly describe additional physician's involvement

    Is there a second medical opinion? Yes No If yes, provide date: Month Day Year

    Name and address of physician who provided second opinion


    Notes:

    Physicians Name Specialty Signature and Stamp Phone


    Date and Place Signed
    Hereby i certify the information and fees given. I authorize the physicians, hospital, or other
    medical entity and related individuals that provided any medical assistance to me or those
    related to me; to provide Ficohsa Insurance Company with all the medical records and billing
    documents. Company Name Company HR Rep Name

    Patient's signature Rep. Signature and Stamp

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