Pacific Life Workforce Benefits pays group hospital indemnity benefits based on admissions and stays, so its claim package ends with WB-128 for the treating physician. The physician confirms the diagnosis, ICD code and diagnosis date, whether the patient was seen in the emergency room, hospital and ICU admission and discharge dates, any surgery or diagnostic exam, therapy ordered and work-status dates.
Section 1 identifies the primary insured and the patient, with names, birth dates and relationship. The attending physician completes Section 2 and signs with specialty and tax ID; the insured completes the separate Insured/Patient Statement in the package.
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Group Hospital Indemnity – Attending Physician Statement
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The treating physician completes Section 2, Patient's Medical Condition, and signs and dates the end of the form. Section 1 identifies the primary insured and the patient, who may be the insured, a spouse, a domestic partner or a child. The insured completes the separate claim statement.
The package instructions ask for hospital discharge summaries or medical records that support the claim. The physician statement itself asks the physician to provide copies of supporting medical information based on the condition. A signed WB-54 authorization is recommended so Pacific Life can obtain records.