Income Protection / Business Expenses Initial Treating Doctor s Report

Transcription

1 Insurance with MLC Income Protection / Business Expenses Initial Treating Doctor s Report Important information Any cost associated with the completion of this form is the responsibility of the Insured. Please fully answer all questions to ensure the Insured s claim is assessed as quickly as possible. Missing or incomplete information may delay the assessment of the claim. Please ensure your writing is clear and legible. This form must be completed by a Registered Medical Practitioner. Allied healthcare providers such as physiotherapists, chiropractors and psychologists are not deemed to be Registered Medical Practitioners for the purpose of completing this form. If you have any questions regarding the completion of this form or if you would like to discuss the Insured s claim please contact us via our toll free number below. We are able to accept a copy of this completed form but reserve the right to obtain the original signed form. If there is insufficient space to fully answer a question, please use page 5. Claims Hotline Insured s details Policy number(s) Insured s name Date of birth (DD/MM/YYYY) Height Weight cm kg Are you the Insured s usual treating doctor? No Yes How long has the Insured been attending you and/or your surgery? Years Months MLC Limited (MLC) ABN AFSL NULIS Nominees (Australia) Limited (Trustee) ABN AFSL Trustee for the MLC Super Fund ABN Income Protection / Business Expenses Initial Treating Doctor s Report Page 1 of 6

2 Disability details 1 Is your disability the result of: (Tick ONE option only) Accident Please go to question 2 Illness Please go to question 3 2 Accident only Nature of injury/diagnosis How did the accident occur? Date of accident (DD/MM/YYYY) Please go to question 4 3 Illness only Nature of illness/diagnosis Date symptoms began (DD/MM/YYYY) 4 When did you first see the Insured for the current medical condition? (DD/MM/YYYY) 5 What are the Insured s current symptoms and how severe are these symptoms (ie mild, moderate or severe)? 6 Have any tests/investigations been undertaken? No Please go to question 7 Type of tests/investigations Results Please attach copies of these results. 7 What date did the Insured cease work as a result of their current medical condition? (DD/MM/YYYY) Page 2 of 6 Income Protection / Business Expenses Initial Treating Doctor s Report

3 Treatment details 8 Please provide all the dates the Insured has consulted you in relation to their current medical condition. 9 What treatment is the Insured currently receiving for their medical condition? (eg medication, physiotherapy etc). Please also detail past or proposed treatment plan. 10 Was the Insured admitted to hospital for their current condition? No Please go to question 11 Name of hospital Address of hospital Reason for admission Postcode Admission date (DD/MM/YYYY) Discharge date (DD/MM/YYYY) Please provide a copy of the hospital discharge summary. 11 Has the Insured consulted or been referred to any other doctor or healthcare provider for their current medical condition? No Please go to question 12 Name of Doctor or healthcare provider Speciality 12 Would the Insured benefit from a vocational rehabilitation programme to assist in their return to work? No Please go to question 13 Income Protection / Business Expenses Initial Treating Doctor s Report Page 3 of 6

4 Prior medical history details 13 Has the Insured ever suffered the same or similar injury/illness in the past? No Please go to question 14 including dates condition(s) occurred 14 Are there any other factors or medical conditions which may delay the Insured s recovery or impair their ability to return to work? No Please go to question 15 Occupation and capacity to work details 15 What is the Insured s occupation? 16 Prior to disablement, what were the Insured s usual occupational duties? 17 How do the Insured s symptoms prevent them from working? 18 What duties is the Insured capable of performing in spite of their disability? 19 Has the Insured been totally disabled (ie unable to work and not working) as a result of their current medical condition? No Please go to question 20 Yes For what period? From (DD/MM/YYYY) To (DD/MM/YYYY) Page 4 of 6 Income Protection / Business Expenses Initial Treating Doctor s Report

5 Occupation and capacity to work details (continued) 20 Has the Insured returned to work? No Please go to question 21 Yes When did the Insured return to work? Part time (DD/MM/YYYY) Full time (DD/MM/YYYY) 21 If the Insured has not yet returned to work, when do you expect them to be fit to return to work? Part time (DD/MM/YYYY) Full time (DD/MM/YYYY) 22 Have medical certificates or reports been provided to any other organisation, insurer or government department in relation to the Insured s current medical condition (eg Workers Compensation insurer, Centrelink, DVA etc)? No Additional information Please use this section to provide additional information. If providing additional information to a question please note the question number to which the additional information refers to. Page number Question number Further information Income Protection / Business Expenses Initial Treating Doctor s Report Page 5 of 6

6 Declaration and authority I hereby certify that I have personally attended the above patient and that the statements and information supplied by me on this form are true and complete. I acknowledge that: This information is provided for the primary purpose of the assessment and investigation of a claim under a policy insured with MLC Limited (MLC). MLC may provide copies of this form to third parties such as claims assessors, investigators, medical professionals, healthcare providers, insurance reference services, credit reference services, legal or accounting firms, auditors, employers, consultants or reinsurers, from whom MLC seeks an independent report, or to any other person or organisation deemed necessary to assist in the assessment or investigation of this claim and policy. A photocopy of this authority is as valid as the original. Name of Medical Practitioner (PLEASE PRINT) Signature Date (DD/MM/YYYY) Address Postcode Qualifications Telephone Fax address Send us your form Please mail this completed, signed and dated form and any attachments to: MLC Claims PO Box 200 North Sydney NSW 2059 A Page 6 of 6 Income Protection / Business Expenses Initial Treating Doctor s Report