Disability Claim Form - American Fidelity Employer Benefits …
https://americanfidelity.com/media/1178/bn-658.pdf
Faster, Easier Claim FilingTwo Ways to RegisterApple App Store or Google PlayClaim Filing Instructions for Mail or Fax:Disability InformationEmployer’s Report of Claim Salary at Time of Disability for Education EmployersEmployer SignatureAttending Physician Statement ImpairmentsPhysician InformationAuthorization to Obtain Information Including Protected Health InformationClaim Form Fraud Statements Attending Physician’s Name & Title: (print) decline Specialty: Phone: (with area code) Fax: (with area code) Mailing Address: (street, city, state, zip) Form Completed By: (Name & Title) Signature: Date: (MM/DD/YY) If you require completion of your own authorization for the release of medical records please submit the form along with the physi... File Size: 654KB Page Count: 6
Attending Physician’s Name & Title: (print) decline Specialty: Phone: (with area code) Fax: (with area code) Mailing Address: (street, city, state, zip) Form Completed By: (Name & Title) Signature: Date: (MM/DD/YY) If you require completion of your own authorization for the release of medical records please submit the form along with the physi...
File Size: 654KB
Page Count: 6
DA: 47 PA: 95 MOZ Rank: 17