Attending Physician s Report

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1 Attending Physician s Report t for use in the United Kingdom Doctor s name Doctor s address XIM/APR Doctor s fax number Doctor s Application reference Please return to:

2 Patient Name of Birth Address Insurance applied for International Attending Physician s Report. t for use in the United Kingdom Dear Doctor, The above patient has applied for insurance. Please use your patient s medical records to fill in this form and return this to me at the address on the front page. We will pay you a fee of USD for your report (or the equivalent in your local currency). Please complete the attached payment form, so we can make payment directly to your bank account. Please read the following points. You do not need to examine or interview your patient. Only our employees or the employees of the company which provides insurance for us will see the information you provide and only if they have a business need to do so. Access to information is controlled by our confidentiality policy which meets local and international standards. We will not use the information you supply to assess insurance applications from anyone other than the applicant. Once we receive the complete report, we will send you the agreed fee. Even if the patient s records are limited because he or she is a new patient or does not see you often, please complete the report anyway. We do not require information on predictive genetic tests. You must not provide information on predictive genetic tests that show the patient has an increased risk of disease. You may include information that shows the patient has a normal or reduced risk of disease. More background about the type of information we need is at the end of the report. I am enclosing a copy of your patient s signed permission for you to fill in this report. Thank you, W P Stephens Dr W P Stephens MD FRCP Principal Medical Officer Friends Provident International XIM/APR Page 2

3 Attending Physician s Report Please use black ink or type, and complete this report in English. We will treat any information you provide strictly in line with our confidentiality policy. This keeps to the guidelines issued by the Association of British Insurers (ABI). We will not use the information to assess insurance applications from anyone other than the applicant. Applicant s health declaration This person has provided the following information: Please make sure that you include the details of this when completing the rest of this form General 1 From when do the patient s records in your possession begin? If this period is not continuous, please give reasons for any gaps. Current health 2a Is the patient currently receiving medical care medication or treatment including repeat prescriptions If, please give details of all relevant prescribed drugs and dosages. 2b Are you waiting for the results of any referrals or tests? If, please give details of relevant referrals or tests. Relevant test results 3 Please provide any blood pressure readings taken in the last three years. Systolic Diastolic Treatment XIM/APR Page 3

4 Relevant test results continued 4 Please provide the latest lipids and height and weight measurements. Cholesterol HDL LDL Triglycerides Treatment Height Weight 5 Please give details of biopsies, blood tests, electrocardiograms, urinalyses, x-rays and other investigations. Nature of investigation Result, and whether controlled You should not include: negative tests for HIV, Hepatitis B or C incidences of sexuallytransmitted diseases unless there are long-term health implications Past health 6 If the patient has had any relevant illness, trauma, referrals for specialist advice or treatment, hospital admissions, consultations with you, or any other medical adviser, therapist or counsellor, please give details. As insurers we are usually concerned with rates of death and disease over the longer term. In particular, we are interested in the following: malignancy, cardiovascular disease, diabetes and degenerative disease musculoskeletal disease or injury, for example, arthritis, rheumatism, back problem or any other disorder of the joints or muscles anxiety state, depression, neurosis, psychosis, stress or fatigue suicidal tendencies or attempts conditions related to drug or alcohol misuse or smoking or chewing tobacco Episode or medical condition Investigations carried out, treatment or other management regime (eg change in diet or reduction in smoking) and outcome How long the episode lasted and whether it is continuing XIM/APR Page 4

5 Negative underwriting decisions 7 Insurance companies must provide, if asked, written reasons to their clients for: the premiums they charge reducing the insurance cover that is provided refusing an insurance application rejecting a claim cancelling a policy The Principal Medical Officer explains the company s reasoning. We will tell people who want to discuss the health implications of anything that is revealed during the insurance process to contact you, their regular doctor. You will not have to explain actuarial or underwriting decisions. Is there any information in your report that our Principal Medical Officer should not release to the patient, because this would cause serious physical or mental harm to the patient or another person? If, please give details Have you attached any additional information, for example, copy hospital letters? Family history 8 Please provide details of any first-degree relatives (parents or siblings) that have had: heart disease; stroke; diabetes; cancer; multiple sclerosis; Alzheimer s disease or any other familial condition before age 60. You must not reveal information about a patient s family member that came from any source other than the patient who this report is about. Attending Physician s Declaration Is there any information in your report that our Principal Medical Officer should not release to the patient, because it would cause serious physical or mental harm to the patient or another person? If, please give details Signed Name Qualifications Medical centre stamp XIM/APR Page 5

6 Medical Information and Insurance An overview of the type of information that is relevant to different types of insurance policy. Life assurance We must work out the risk of the applicant dying before the end of the term of the policy. As a result, we are interested in the diagnosis, treatment, severity and prognosis of a medical condition which will result in early death - not the applicant s quality of life. n-life-threatening conditions or illnesses are not relevant when we assess life assurance. Examples are colds, flu, routine vaccinations, wisdom teeth, uncomplicated pregnancies, contraception, minor breaks and sprains, common childhood complaints where there have been no further complications. Critical Illness We are concerned with the possibility of a critical illness occurring in the applicant. Examples of the main critical illnesses we cover are blindness, cancer, coronary artery by-pass surgery, deafness, heart attack, heart valve surgery, major organ transplant, stroke, MS and permanent disability. As a result, we need information about any of the conditions covered, and other health factors that affect the likelihood of your patient developing a critical illness. We are also interested in medical conditions which mean that they may become permanently disabled or unable to carry out any part of his or her occupation. Payment Instruction Form Please return this report to the Principal Medical Officer at the address on the front page, along with a copy of your invoice. Should you wish to receive payment in your local currency, please provide your full bank details so we can arrange for a telephonic transfer direct to your account. Our standard fee is USD for your report (or the equivalent in your local currency). Please amend below if you require a different currency or an increased fee has been agreed. Account details Details of bank account to which payments are to be credited. Amount Currency Name of bank Address of bank Name of account holder Account number Swift code IBAN number BIC number Friends Provident International Limited Registered & Head Office: Royal Court, Castletown, Isle of Man, British Isles, IM9 1RA Telephone: +44(0) Fax: +44(0) Website: Incorporated company limited by shares Registered in the Isle of Man Authorised by the Isle of Man Insurance & Pensions Authority Provider of life assurance and investment products Authorised by the Office of the Commissioner of Insurance to conduct long-term insurance business in Hong Kong Registered in the United Arab Emirates as an insurance company (Registration.76) and as a foreign company (Registration. 2013) Authorised by the United Arab Emirates Insurance Authority to conduct life insurance and savings business Registered in Singapore. F06835G Registered by the Monetary Authority of Singapore to conduct life insurance business in Singapore XIM/APR (37889)

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