Forms

We ask all of our disability patients to sign a Disclosure Authorization (Release of Information) Form* (PDF) before we contact you for their medical information. With the form, the patient gives you permission to release his or her medical records and provide treatment information to us. The form also ensures that we are compliant with Health Insurance Portability and Accountability Act (HIPAA) regulations when requesting the patient's protected health information (PHI). Once we've received signed authorization, the claim manager will call you to collect as much patient information as possible.

The claim manager may ask you to provide further details about your patient's condition. To submit the additional, clinical patient information, choose the appropriate link below. We've provided brief explanations of the usual circumstances behind the claim manager's requests.

Please complete all requested forms* and send them to the fax number the case manager has provided.

Medical Request Form* (PDF)
The claim manager or nurse case manager requests initial medical information at the beginning of a new short-term or long-term disability claim.

Follow-up Medical Request Form* (PDF)
You have already provided initial information, but the case manager or nurse case manager requests a status update.

Physical Abilities Assessment Form* (PDF)
The claim manager or nurse case manager needs specific information about a patient's ability to engage in certain physical activities over a defined period of time.

Behavioral Health Questionnaire* (PDF)
The claim manager or nurse case manager requests medical information for a patient with a psychiatric claim.