Unum uses this 9-page form for supplemental health hospital indemnity claims. The Attending Physician or Provider of Service Statement on pages 7 and 8 confirms the diagnosis and ICD code, the reason for treatment, and the dates and times of emergency room, ambulance or hospital stays. Diagnostic testing and outpatient surgery claims add the surgery date, place of service and CPT code.
The attending physician or treating provider completes sections A and D for every claim, section B for emergency room and hospital confinement, and section C for diagnostic testing and outpatient surgery. The insured completes the Insured/Patient Statement and signs the authorization.
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Hospital Claim Form
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Section A and section D for all claims. Add section B for emergency room, ambulance and hospital confinement claims, with admission and discharge dates and times, place of service and diagnosis code. Add section C for diagnostic tests and outpatient surgery, with the CPT code and related ICD code.
The statement is titled Attending Physician or Provider of Service Statement and is completed by the attending physician or treating provider. The signature block asks for the provider's specialty, degree, tax ID and whether they are related to the patient.