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 C15CLM-ST: Cancer and ICU Statement
Family Heritage Life uses this one-page supplemental physician's statement as side 2 of both its cancer claim and its intensive care claim. For cancer, the treating physician reports when cancer was first diagnosed, whether this is a recurrence, hospital or outpatient dates, services rendered and CPT codes. For intensive care claims, it records the reason for hospitalization and ICU dates.
Who completes it
The policyholder completes side 1 of the cancer or ICU 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
- Item 7 lists services rendered: biopsy, surgery, chemotherapy, radiation, hospice and skilled nursing, with surgery CPT codes in item 8.
- For a recurrence, give the date of recurrence and the date of the last known cancer treatment.
- Both blocks ask whether the patient has ever been diagnosed with AIDS or ARC, and the intensive care block asks about heart attack, heart disease or stroke history.
- Globe Life lists a travel log form with the Family Heritage cancer claim forms, alongside the claim form and this physician's statement.
Get the official form
Download the current version from the source each time; forms change without notice.
Supplemental Physician's Statement (Cancer / ICU 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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
Is the Family Heritage cancer physician statement the same as the ICU one?
Yes. Form C15CLM-ST appears as side 2 of both the cancer claim and the intensive care claim, with a cancer block and an intensive care block on one page. The physician completes the block that matches the claim being filed.
What cancer details does C15CLM-ST ask for?
The cancer block asks for diagnosis codes, when any cancer was first diagnosed, when the physician was first consulted for the current condition, whether it is a recurrence, the referring physician, hospitalization or outpatient service dates, services such as biopsy or chemotherapy, and surgery CPT codes.