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 H7CLM-ST: Heart and Stroke Statement
Family Heritage Life uses this one-page supplemental physician's statement as side 2 of its heart and stroke policy claim. The treating physician reports any history of heart disease, heart attack or stroke with first diagnosis and treatment dates, diagnosis codes, the reason for hospitalization, surgical and other procedure codes, and ICU confinement dates.
Who completes it
The policyholder completes side 1, the heart and stroke 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 4 asks whether the condition was diagnosed before this admission, and item 5 whether the hospitalization was solely due to this condition, with admission and discharge dates.
- Up to three diagnosis codes, three surgical CPT codes and three other procedure codes can be listed on the form.
- Item 9 asks whether the office has records of the patient's past medical history, and item 10 asks about any AIDS or ARC diagnosis.
- It is a one-page flat PDF with no fillable fields, so the physician's office completes it on a printed copy.
Get the official form
Download the current version from the source each time; forms change without notice.
Supplemental Physician's Statement (Heart and Stroke 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
What does Family Heritage form H7CLM-ST ask?
It asks whether the patient has ever been diagnosed with or treated for heart disease, heart attack or stroke, first diagnosis and treatment dates, diagnosis codes, reason for hospitalization, prior diagnosis before admission, admission and discharge dates, procedure codes, ICU dates, past history records and any AIDS or ARC diagnosis.
How is a Family Heritage heart and stroke claim filed?
The physician's side 2 is returned with the policyholder's side 1 heart claim form. Globe Life's claims page lists eClaims online submission with document upload, plus mail and fax to the Family Heritage claims department.