An employee claiming under a Pacific Life Workforce Benefits group accident policy has the treating physician complete WB-126, the last page of the claim package. The physician confirms the diagnosis and ICD code, the injury date and accident description, emergency room, hospital and ICU dates, any surgery or diagnostic exam, therapy prescribed, and the dates the patient was told to stop and return to work.
Section 1 identifies the primary insured and the patient, with the patient's relationship to the insured. The attending physician completes Section 2 and signs with specialty and tax ID; the insured separately completes the WB-125 Insured/Patient Statement.
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Group Accident – Attending Physician Statement
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The form asks the physician to provide copies of supporting medical information based on the condition. The package instructions add hospital discharge summaries and medical records that support the claim, along with the insured's statement and, as recommended, the signed WB-54 authorization.
Yes. Section 1 has check boxes for the patient's relationship to the primary insured: self, spouse, domestic partner or child. Both the primary insured's and the patient's names and birth dates go at the top before the physician completes Section 2.