Trustmark Voluntary Benefits asks for this 2-page Attending Physician's Statement when a policy owner claims under a Critical HealthEvents policy. The physician gives the date of diagnosis, first consultation, prior similar conditions and hospitalization dates, then checks the qualifying condition. Each condition lists the documentation Trustmark expects, such as a pathology report for cancer or neuroimaging for stroke.
The physician or supplier completes, signs and dates the statement, including degree, specialty and SSN or employer ID. The patient or an authorized person signs the patient section, and the policy owner files the separate A112-2509 initial claim form.
Download the current version from the source each time; forms change without notice.
Critical HealthEvents Claim – Attending Physician's Statement
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For stroke, the Critical HealthEvents statement asks for documented neurological deficits and/or neuroimaging studies. For a transient ischemic attack, it asks for the clinical exam and diagnostic evaluation. Check the condition, give the date of diagnosis and attach the supporting records.
No. A112-2509_APS supports Critical HealthEvents claims, while Trustmark's Critical Illness and Cancer policies use A112-2497, whose physician statement covers a different condition list. Both are posted on Trustmark's Voluntary Benefits forms page.