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VRZ COMM 5320 (01/06) eF
ATTENDING PHYSICIANS STATEMENT
Instructions for completing the claim form:
1. Complete all applicable areas of the claim form.
2. Sign the claim form.
3. Fax this claim form to expedite your claim – retain original for your records.
The following section must be completed and signed by the employee/patient. Occupation
Any fee for the completion of this form is the patient’s responsibility.
Group Report #
I hereby authorize my physician to release any information acquired in the course of examination or treatment. Date of Birth
Signature of Employee __________________________________________ Date ____________________
The following section must be completed and signed by the attending physician.
The purpose of this report is to assist us in making a disability determination. Please complete all applicable sections of this
form. A MetLife claim representative may telephone your office if additional information is needed.
Symptoms result from: Injury Illness
Is condition work-related? Yes No
Initial date of treatment ________________________________ Most recent date of treatment _____________________
Did you advise the patient to cease doing any job, including but not limited to the above noted occupation?
Yes No and if yes, the date __________________________________________
Names and Phone Numbers of the providers the patient was referred to:
_________________________ _________________________ _________________________
Has patient been hospitalized? Yes No If Yes, Day Confined __________________ Through ______________
Name and address of facility
Diagnosis and Treatment
Primary ICD-9 _______ - __________________ Diagnosis __________________________________________________
Secondary ICD-9 _______ - _______________ Diagnosis ________________________________________