Physician Statement Form
To be completed by Primary Insured
Primary Insureds Name: ___________________________
Policy Number: ___________________________________
Insurance Purchase Date: ____ / _____ / _________
To be completed by Examining Physician
Patient Information
Patients Name: ___________________________________
Date of Birth: _____ / ________ / _____________
Street Address: ___________________________________
City: ______________
State: ____
Zip Code: _______
Physician Information
Examining Physicians Name: ________________________
Specialty: _______________________________________
Street Address: ___________________________________
City: ______________
Phone: (______) ______ -- ____________
Fax:
State: ____
Zip Code: _______
(______) ______ -- ____________
Are you the patients primary care physician?
No
Who is this patients primary care physician?
Name: __________________________________________
Yes
Phone: (_____) _______ -- ___________
Was the patient referred to you by the primary care
physician?
Yes
Mail to: ACCESS AMERICA, P.O. BOX 72031, RICHMOND, VA 23255-2031
Call: 800-334-7525 Fax to: 804-673-1469
We are available 24 hours a day.
Insurance underwritten by BCS Insurance Company or Jefferson Insurance Company
Please refer to your policy or letter of confirmation to determine your underwriter
Plan Administered by World Access Service Corp., a company of Mondial Assistance
No
Patients Diagnosis:
Did you perform an actual examination?
Yes
No
Date of the exam: ____ / _____ / _________
Please indicate the primary diagnosis for which you examined the patient:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
ICD-9 Code: _______________
Date symptoms first appeared or accident occurred: ____ / _____ / _________
Is this condition a complication of an underlying condition?
Yes (specify below)
No
__________________________________________________________________________________________________
Please list the dates of the patients office visits in the 120 days before the insurance purchase date, noted above. Circle
the dates where you treated the patient for the above stated condition.
____ / _____ / ___________ ____ / _____ / ___________ ____ / _____ / ___________ ____ / _____ / ___________
____ / _____ / ___________
____ / _____ / ___________
____ / _____ / ___________
____ / _____ / ___________
Did you advise the trip be cancelled or interrupted due to the patients medical condition?
Yes Date: ___ / ___ / _________
No
Please explain why you made this recommendation.
Provide details on the circumstances and medical diagnosis
of the patient that you consider relevant to the insureds
decision to cancel or interrupt their trip due to injury or
illness.
Please explain why you did not make this recommendation.
Provide details on the circumstances and medical diagnosis
of the patient that you consider relevant to the insureds
decision to cancel or interrupt their trip due to injury or
illness.
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
If the patient is the insured, on what date did he/she become medically unable to travel?
___ / ___ / ________
By my signature and stamp below, I hereby certify that the above is true and correct
Physician Signature: _________________________________________________ Date ____/____/______
Physician Stamp:
Mail to: ACCESS AMERICA, P.O. BOX 72031, RICHMOND, VA 23225-2031
Call: 800-334-7525 Fax to: 804-673-1469
We are available 24 hours a day.
Insurance underwritten by BCS Insurance Company or Jefferson Insurance Company
Please refer to your policy or letter of confirmation to determine your underwriter
Plan Administered by World Access Service Corp., a company of Mondial Assistance
