Short Term Disability Claim Form
rev 9.19
Employee Form
ALL questions must be answered to avoid a possible delay. Please return completed
form to employer. Claims are subject to review to determine medical appropriateness.
Employee’s Statement of Claim Please Print
Full Name
Social Security Number
Phone Number
Mailing Address (if different from street address)
City
State
Zip Code
Employer Name
Email address
Date of Birth:
Marital Status:
□
Single
□
Married
□
Widowed
□
Divorced Gender:
□
Male
□
Female
Is the claim a result of a work related illness or injury?
□
Yes
□
No
Is claim due to an accident/injury?
□
Yes
□
No
Have you or will you file a claim for workers compensation
benefits?
□
Yes
□
No
Please provide a detailed description of how injury occurred and location.
Date Disability commenced
Date disability ceased
Have you filed for Social Security Benefits?
□
Yes
□
No
Date that claim was filed:
Date that Social Security benefits
commenced:
Authorization to Release Information: I hereby authorize any providers or Health Care services,
claim administrators, insurers, reinsurers and others
who have legitimate need for such information for the purpose or review, investigation or evaluation of a claim, to supply each other with information
about my health status and the health care services provided to me. I agree that a photographic copy of this authorization is as valid as the original.
Employee Signature Date
Important notice to all employees: Time spent on short-term
disability leaves of absence (including any waiting periods)
will be deducted from your 12-
week leave bank in accordance
with the Family Medical Leave Act of 1993
_____________Employee initials
Any person who knowingly and with intent to defraud any insurance
company or claims administrator or other person files an application for
insurance or statement of claim, containing any materially false information
or conceals for the purpose of misleading information concerning any fact
material thereto, commits a fraudulent insurance act, which is a crime.
____________Employee initials
Treating Physician’s Statement Please Print
Diagnosis
ICD10 Code
Disability due to pregnancy?
□
Yes
□
No
Expected delivery date:
Is Disability due to illness or injury arising from
Patient’s employment?
□
Yes
□
No
Auto related?
□
Yes
□
No
Date of first treatment:
Date of most recent treatment:
Date of next appointment:
Describe course of treatment:
Was the patient hospital confined?
□Yes □No
From: Through:
The patient has been continuously disabled
(unable to work)
From: Through:
The patient should be able to work on/or about:
(Please indicate a specific date to avoid a delay in benefits)
Date and type of surgical
procedure:
Attending Physician (please print)
Physician’s signature (no stamped signatures)
Physician specialty:
Physician’s address:
Telephone number:
Fax number:
Date:
Employer’s Statement Please Print
Employees Name
Occupation
Hourly
Salary
Employment date
Weekly Wage
Weekly Benefit
Employee Status
Active Laid Off Retired
Effective date of coverage
Date disability
commenced
Date disability
ceased
Vacation, Personal, Sick time used Yes No
Dates used:
Date last w orked
Is this a recurrence within 2 weeks of previous disability?
□
Yes
□
No
Has employee returned to work?
□
Yes, Date________________
□
No
Do you have any information which would assist Meritain in determining the merits of this case? Please explain.
Do you have any information regarding worker’s compensation or other disability income benefits that would affect this claim? Please explain
PLEASE CIRCLE THE JOB DEMANDS THAT APPLY IF JOB DESCRIPTION NOT ATTACHED
Demand Level
% of working
or frequency
Occasional
0-33%
1-4 reps per hour
1-32 reps per day
Frequent
34-66%
6-24 reps per hour
33-200 reps per day
Constant
67-100%
>24 reps per hour
>200 reps per hour
Sedentary 10 pounds Negligible Negligible
Light Up to 20 pounds 10 pounds Negligible
Medium Up to 50 pounds 20 pounds 10 pounds
Heavy Up to 100 pounds 50 pounds 20 pounds
Very Heavy Over 100 pounds Over 50 pounds Over 20 pounds
Employee’s job requires: ______% Standing ______% Bending ______% Twisting
If MERITAIN ISSUES THE CHECKS, PLEASE INDICATE INDIVIDUAL APPLICABLE DEDUCTIONS
Federal Tax ______________% State Tax ____________% Other _______________%
PRE-TAX DEDUCTIONS AFTER TAX DEDUCTIONS
MEDICAL INSURANCE $ _____________ CHILD SUPPORT $ ________________
DENTAL INSURANCE $ _____________ SPOUSA L SUPPO RT $ ________________
FLEX $ _____________ OTHER ______________ $ ________________
OTHER _________________ $ _____________ OTHER ______________ $ ________________
Employer’s representative (please print)
Signature of Employer’s representative
Title:
Company Name:
Group Number:
Address:
Phone number: Fax number :
Submit claims to: Meritain Health
Phone: 800-748-0003 x2187 Fax:517-381-6768
Email: Disability@Meritain.com
Short Term Disability Claim Form
Employer Form
Please provide a job description
with claim submission.
1
31.5162017
Authorization for Release of
Protected Health Information (PHI)
My health record is private and is known under the law as “Protected Health Information (PHI)”.
By completing and signing this form, I, or my legal representative, agree to allow Meritain Health and any of its parents, subsidiaries and
affiliates, and their respective employees, agents and subcontractors, to share my PHI with the people or companies listed below.
I UND
ERSTAND THAT THIS AUTHORIZATION IS VOLUNTARY.
Please submit a separate Authorization for Release of Protected Health Information (PHI) for each plan member for whom
Meritain Health is being requested to disclose PHI to a third party. If both sides of this form are not completed, as applicable,
Meritain Health will be unable to process your request. Incomplete authorization requests will be returned.
Please print all responses
1. Member Information
Last Name First Name Middle Initial
ID Number Group Number or Group Name Birth Date (MM/DD/YYY) Phone Number (Including Area Code)
Street Address City State Zip Code
2. Employee Information (Please complete this section if the employee is not the member whose records are being requested.)
Last Name First Name Middle Initial
ID Number Group Number or Group Name Birth Date (MM/DD/YYY) Phone Number (Including Area Code)
Street Address City State Zip Code
3. I authorize the individual(s) or company(ies) identified below to receive PHI pertaining to the member identified in Section 1 above.*
Individual or Company Authorized to Receive PHI Phone Number (Including Area Code)
Street Address City State Zip Code
Individual or Company Authorized to Receive PHI Phone Number (Including Area Code)
Street Address City State Zip Code
Individual or Company Authorized to Receive PHI Phone Number (Including Area Code)
Street Address City State Zip Code
4. Purpose(s) for this Authorization
I only want to share the PHI I have checked below. This authorization cannot be used to share psychotherapy notes. (Check all that are
appropriate)
An
y information requested
Health (this includes medical,
dental, pharmacy, vision, and flexible spending account information)
Disability Behavioral Health (e.g. mental
health, drug and alcohol abuse treatment, but NOT psychotherapy no
tes)
Life Benefits Long term car
e
Patient manag
ement record
s Application or enrollment infor
m
ation
Claim status
Cl
aim records
Other
(please explain) ________________________________________________________________
This authorization will be valid for 1 year from the date signed, unless you indicate a shorter period below.
through
MM/DD/YYYY MM/DD/YYYY
Meritain Health
2
31.5162017
*NOTICE TO RECIPIENT(S) OF INFORMATION (Section 3 on page 1):
Information disclosed to you pertaining to certain conditions, such as treatment for alcohol or drug abuse, HIV/AIDS and other sexually transmitted diseases,
behavioral health, and genetic marker information is protected by various federal and state laws which prohibit any further disclosure of this information by you
without the express written consent of the person to whom it pertains or as otherwise permitted by such laws. Any unauthorized further disclosure in violation of
state or federal law may result in a fine or
j
ail sentence or both. A general authorization for the release of medical or other information is NOT sufficient consent
for release of these types of information. The federal rule at 42 CFR Part 2 restricts use of the information disclosed to criminally investigate or prosecute any
alcohol or drug abuse patient.
5. IMPORTANT: Your signature below means that you understand and agree to the following
My PHI that I agree to share may be sensitive. It may include diagnosis and treatment information, including information pertaining to chronic diseases,
behavioral health
conditions, alcohol or substance abuse, communicable diseases, sexually transmitted diseases, HIV/AIDS, and/or genetic
marker
information.
Whoever gets my PHI may share it with others. That means federal or state privacy laws may no longer protect my PHI. Oklahoma Residents: You ma
y
have additional protections under
Section 1-502.2 of the Oklahoma Statutes if the type of information to be released relates to HIV/AIDS and/or sexually
transmitted disease information.
If we receive requests for copies of claims/ encounter information from the individual or company you have named in Section 3, we may charge
a
reasonable fee
(except where prohibited by law) to defray our copyi
ng and mailing costs.
I can get a copy of this authorization form that I have signed by sending Meritain Health a signed request using the address at the bottom of this page.
Your ability to enroll in a Meritain Health plan, and your eligibility for benefits and payment for services, will not be affected if you do not
sign this form.
(Ho
wever, without your signature, your request to release information to the individual(s) named in Section 3 above will not be honored
.)
You may receive a copy of this signed form if you ask for it by writing to the address listed at the bottom of this page.
You may cancel or change this authorization at any time by notifying Meritain Health in writing at the address below. Revoking this authorization w
ill not
have an
y affect on actions that Meritain Health took before getting my request..
6. Signature of Member or Member’s Legal Representative
ATTENTION:
My signature is required if any of the below apply:
I am 18 years of age or older
I am a minor under the age of 18 and I am either married or emancipated
The information being disclosed pertains to drug or alcoho
l treatment
The information being disclosed pertains to one of the following conditions and my state allows me to be treated even if my pa
rents or
lega
l guardian do not agree with my decisio
n:
- Mental
health
- Sexually transmitted disease (including HIV/AIDS)
- Reproductive health (including contraception, prenatal care and abortion)
- General medical and dental health
Signature Date Signature Date
Print Name Print Name
If the person signing this Authorization is not the member, describe relationship to the member (i.e. Parent/Legal Guardian, Legal Representative):
If this authorization is being signed by the Member’s Legal Representative, you must provide the relevant legal document
authorizing you to act on the Member’s behalf (e.g. Power of Attorney, Legal Guardianship, Executor of Estate).
If you are making this request on behalf of a minor child, we may require additional information before this request is considered
complete.
