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    1) John Doe, a 53 year old male, is applying for long term disability benefits. He worked as a delivery driver for ABC Distributors until January 15, 2020 when he stopped working due to back pain. 2) His primary physician, Dr. Smith, notes his primary diagnosis is degenerative disc disease of the lumbar spine with sciatica. Secondary complications include depression and anxiety related to his chronic pain. 3) The physician statement provides medical information to support John Doe's long term disability claim for an condition preventing him from performing the regular duties of his own occupation.

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    Img S2 P.1

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    6 views1 page
    1) John Doe, a 53 year old male, is applying for long term disability benefits. He worked as a delivery driver for ABC Distributors until January 15, 2020 when he stopped working due to back pain. 2) His primary physician, Dr. Smith, notes his primary diagnosis is degenerative disc disease of the lumbar spine with sciatica. Secondary complications include depression and anxiety related to his chronic pain. 3) The physician statement provides medical information to support John Doe's long term disability claim for an condition preventing him from performing the regular duties of his own occupation.

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    1) John Doe, a 53 year old male, is applying for long term disability benefits. He worked as a delivery driver for ABC Distributors until January 15, 2020 when he stopped working due to back pain. 2) His primary physician, Dr. Smith, notes his primary diagnosis is degenerative disc disease of the lumbar spine with sciatica. Secondary complications include depression and anxiety related to his chronic pain. 3) The physician statement provides medical information to support John Doe's long term disability claim for an condition preventing him from performing the regular duties of his own occupation.

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

    Img S2 P.1

    Uploaded by

    larrybecker59
    1) John Doe, a 53 year old male, is applying for long term disability benefits. He worked as a delivery driver for ABC Distributors until January 15, 2020 when he stopped working due to back pain. 2) His primary physician, Dr. Smith, notes his primary diagnosis is degenerative disc disease of the lumbar spine with sciatica. Secondary complications include depression and anxiety related to his chronic pain. 3) The physician statement provides medical information to support John Doe's long term disability claim for an condition preventing him from performing the regular duties of his own occupation.

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    © All Rights Reserved
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    of 1

    ,# BLL.

    IE GFIETSS' ALBEFITA ATTENDING PHYSICIAN STATEMENT


    LONG TERM DISABILITY CLAIM
    10009 108 Street NW, Edmonton, Alberta T5J 3C5
    Telephone: 587 -7 56-8631 or 1 -800-763-6206
    F a* 7 80 - 441 -2605 Tol l-free faxr 1 -855-660-2605

    ab.bluecross.ca

    Submit directly to Alberta Blue Cross, Life & Disability Services. See contact informotion above.
    It is the responsibility of the plan member to submit the Employee Stotement and Attending Physician Statement.
    The plon member is responsible for submitting this completed form and accepting any charges for its completion.

    1. This section to be completed by employee (plan member)


    Last name First name M ddle initial Birth date (YYYY-t\4M-DD) Gender

    frecVe< N o= sr-ou Lqboio a /aa tru Elr


    Mailing address City/town Province Postal code

    5 ? G, \\es r€- C*e scew t (ec\. \e e, r Ae Pa r"r


    Home telephone Cell phone Email address Dominant hand Height Weight
    *t ,3
    :e&-.5'i', '-/ t'{ I03 -3q l-}a 31 \i0tr-*^",*. i:re ke t* d"'7S"1,:.& * i, { # v*: E l"rt 1#q
    Employer's name CEf.{vo-\ Group/policy number Section lDnumber Date last worked (YYYY-MM-DD) Date returned to work/expected
    a/

    213Acqt7 - -
    A -fo Po-.ts Di strib gkrs A ?a# s
    ol aoal/ Os./ ov return date (YYYY-MM-DD)

    Please list your present medications

    Name of medication Dosage (mg) How often?


    1

    t * L l*4"y (L itC 'Tatzc a clcx,,1 ,

    ' Ta"l-t*\&t+TL,v\ ,c -'--,r1


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    ' i ':,tLr{
    4.
    C I
    5.
    .;,( a

    I hereby au$orize the release of health information in my file by the health care provider listed on this form to A lh{ta Blue Cross, Blue Crois Life lnsur"n."
    ffip.ny of Canada*
    and/or its authorized agents for the purposes of determining eligibility for coverage, assessment, paying claims, aYdit, investigation, underwriting, administMtion and claims
    management. This health information includes, but is not limited to, copies of all consultation reports, my medical history, clinical notes, test results and hospital records. Medical
    and health information excludes genetic test results.
    I understand that I can revoke this consent at any time in writing; however, ifconsent is withheld or revoked coverage may be denied or rescinded.

    I understand why I have been asked to disclose this information, and am aware ofthe risks and benefits ofconsenting, or refusing to consent, to the disclosure.
    I agree that this consent shall be effective on the date noted below and shall be valid for the duration of the time my benefit coverage is in force
    I agree that a copy or electronic version ofthis authorization shall be as valid as the original.

    privacy6lab.bluecross.ca.

    signaqrg€{employee (plan member) /) I Date of consent (YYYY-MM-DD)

    :f W'u\rvla- #t-{)wt\-,

    2. Attending physician statement TO BE COMPLETED ByTHLDOCTOR

    I am the ing physician f|ConsultingspecialistEother(pleasespecify)


    PLEASE COMPLETE TO THE BEST OF YOUR KNOWTEDGE

    fil';A^'"X" osk;, a,ftl*k" {-'7M kw-


    Primary

    Secondary and/or complications

    {)css,teb- 1UIL,{LLJt ,-0 t rr' I iVUrw)e J*,,*6n-

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