Family Heritage Life, a Globe Life company, uses this one-page supplemental physician's statement as side 2 of its accident policy claim. The treating physician documents the diagnosis and codes, the accident date and nature of the injury, hospitalization and CPT procedure codes. A separate block on the same page covers intensive care claims, including ICU confinement dates.
The policyholder completes side 1, the accident claim form. The treating physician completes and signs side 2, and whoever fills it out prints their name and position.
Download the current version from the source each time; forms change without notice.
Supplemental Physician's Statement (Accident claim)
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The treating physician completes it as side 2 of the Family Heritage accident claim. It asks for diagnosis and codes, accident date and location, nature of injury, first and latest visits, prior similar conditions, referring physician, intoxicant use, hospitalization, CPT codes and whether past medical history records are available.
The physician's side 2 is returned with the policyholder's side 1 accident claim form. Globe Life's claims page lists online submission through eClaims, which accepts uploaded documents, as well as mail and fax to the Family Heritage claims department.