Treating physician documents the accidental injury and treatment for a Family Heritage accident policy claim.
- Completed by
- Treating physician
- Issued by
- Family Heritage Life Insurance Company of America (Globe Life)
- Format
- Language
- English
Family Heritage Hospital Indemnity Physician Statement
Family Heritage Life uses this one-page physician's statement as side 2 of its hospital indemnity claim. The treating physician states the reason for hospital confinement, admission and discharge dates, diagnosis and codes, and whether the condition was due to an accident. Unlike the other Family Heritage physician statements, it carries no printed form number.
Who completes it
The policyholder completes side 1, the hospital indemnity claim form. The treating physician completes and signs side 2, with the name and title of the person completing it.
Submitting and payment
- How to submit it
- Return side 2 with the policyholder's claim form to the Family Heritage claims department. Globe Life accepts these claims through its eClaims portal, which takes uploaded documents, or by mail or fax.
Good to know
- The physician answers whether the patient was hospitalized solely due to this condition and whether the patient has had the same or a similar condition, with the date diagnosed.
- If the condition was due to an accident, give the accident date and describe the nature of the injury or condition.
- The form asks whether the patient was under the influence of an intoxicant or narcotic, whether it was physician-directed, and whether it contributed to the condition.
- List any applicable procedure codes and any other disease or infirmity affecting the present condition.
Get the official form
Download the current version from the source each time; forms change without notice.
Physician's Statement (Hospital Indemnity claim)
Fill it with Vero
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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.
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Frequently asked questions
Who signs the Family Heritage hospital indemnity physician statement?
Side 2 is headed to be completed and signed by the treating physician. Office staff may record their name and position on the 'completed by' line, but the physician's signature and date are required, along with name, specialty, address and phone.
What dates does the hospital indemnity physician statement ask for?
It asks for the admission and discharge dates of the hospital confinement, the date diagnosed if the patient had the same or a similar condition before, and the accident date if the condition resulted from an accident.