Paid Leave - Attending Physician’s Statement
Send to: Paid Leave Claims, P.O. Box 14806, Lexington, KY 40512 Customer Service: (800) 268-2525, Fax: (610) 807-2684
Documents can be returned securely at www.GuardianAnytime.com.
EMPLOYEE SECTION
1. Employee Name 2. Date of Birth 3. Plan Number 4. Claim Number
/ /
AUTHORIZATION
I authorize any physician, medical practitioner, hospital, clinic, other health facility, consumer reporting agency, the Social Security Administration, the
Medical Information Bureau, insurance or reinsurance company, or employer to release any and all medical and non-medical information in its
possession about me to The Guardian Life Insurance Company of America or its legal representatives. Medical information means all information in
the possession of or derived from providers of health care regarding the medical history, mental or physical condition, or treatment of me. I understand
that Guardian will use the information obtained by this authorization to determine eligibility for insurance or eligibility for benefits under an existing plan.
Guardian will not release any information obtained to any person or organization except to reinsurance companies, the Medical Information Bureau,
or other persons or organizations performing business or legal services in connection with my application, claim, or as may be lawfully required or
permitted, or as I may further authorize. I know that I may request and receive a copy of this authorization. I agree that a photocopy of this authorization
shall be as valid as the original. I agree that this authorization shall be valid for the duration of my claim.
Signature Any person who with intent to defraud any insurance company or other person files an application for insurance or statements of claim containing any materially false
information, or conceals for purpose of misleading information concerning any fact material hereto, commits a fraudulent insurance act, which is a crime, and may also be subject to
civil penalties, or denial of insurance benefits.
Signature: ______________________________________________________________________________ Date: __________________________
PHYSICIAN SECTION
We are reviewing a Paid Leave Claim for your above named patient and require an update on his/her current condition.
1. Date leave first 2. Date of first 3. Most recent 4. Frequency of treatment: Weekly Monthly 5. Next
required: treatment: evaluation: appointment:
Other (specify):
/ / / / / / / /
6. Type of leave required by your patient: Continuous Intermittent Dates of leave: From / / Through / /
If Intermittent, enter the schedule below (days / hours) for which you are approving leave: (ie. _0_ Sun _8_ Mon _0_ Tue _8_ Wed - etc)
SUN MON TUE WED THUR FRI SAT VARIES (explain)
7. Has patient’s condition: Recovered Improved 8. Recovery date: Estimated Actual
Not Changed Retrogressed Full-time Part-time
9. Diagnosis: Specific Limitations / Restrictions:
ICD 10 Code: Clinical data to support diagnosis and restrictions :
10. Current treatment plan (Please be specific, including surgeries (CPT codes) / procedures with dates, medications, therapy, etc.):
11. If pregnancy, provide date of delivery: / / Estimated Actual
Complications, if any
If pregnancy terminated, enter the date: / / Reason: Normal delivery C-Section Miscarriage Abortion
12. Date(s) of emergency room care / hospitalization / Rehab: From / / Through / /
13. Did you refer patient to another physician for treatment or evaluation of the current condition? Yes No If “Yes”, please provide:
Physician Name Specialty Address Phone Number
14. Please include most recent office visit notes and attach or provide additional information as specified below:
Records from / / to / / Include diagnostic study and op reports
15. I certify that the above statements truly describe the patient’s need for medical leave / disability and the estimated duration thereof:
Physician Name (Please Print): Specialty:
Signature: ______________________________________________________________________________________ Date: ____ /____ /____
Address: City: State: Zip:
Telephone Number: ( ) - Fax Number: ( ) - Email Address:
GG-015782-PML (10/20)
