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Family Heritage Life Claim: Medical Provider Statement

Family Heritage Life uses this page of its life claim packet when a death claim is filed on a policy less than two years old. The deceased's medical provider answers seven medical history questions: when the fatal disease or impairment was diagnosed, substance treatment, disabilities, other significant conditions, hospitalizations in the past three years, and practitioners seen in the past five years.

Who completes it

The beneficiary or estate representative completes the life claim form and signs the authorization for release of the deceased's health information. The deceased's medical provider completes and signs the Statement of Medical Provider.

Submitting and payment

How to submit it
Return it with the life claim form to the Family Heritage claims department, through Globe Life's eClaims portal, by mail or by fax.

Good to know

  • Globe Life treats policies under two years old as contestable and gives them additional review, which can lengthen processing.
  • The packet's HIPAA authorization lets providers release the deceased's entire medical record to Family Heritage and stays in force for 24 months.
  • Question 1 asks whether you were the deceased's treating provider, with specialty and duration of care. Attach additional pages if more space is needed.
  • The statement is part of life claim packet FHD1065452 (0925); the claim fraud warning on pages 7 and 8 is to be read before signing.

Get the official form

Download the current version from the source each time; forms change without notice.

Life Claim Form – Statement of Medical Provider

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

When does Family Heritage need a Statement of Medical Provider?

Globe Life's claims page says the Statement of Medical Provider and the authorization form are required for policies under two years old. Those policies are contestable and get additional review. For older policies, the claimant completes only pages 3 and 4 of the life claim form.

What authorization comes with the Family Heritage provider statement?

The packet includes an Authorization for Release of Deceased's Health Information Pursuant to HIPAA, signed by a beneficiary, legal representative, executor or next of kin. It authorizes providers to disclose the deceased's entire medical record to Family Heritage and remains in force for 24 months.