The Pearl Carroll Disability Claim form is a crucial document for individuals seeking disability income benefits. It requires detailed information about the claimant's medical condition, treatment history, and employment status. Completing this form accurately is essential for a smooth claims process, so take the first step by filling it out today.
Click the button below to get started.
The Pearl Carroll Disability Claim form is a crucial document for individuals seeking benefits due to a disability. This form serves as a formal request for disability income and outlines the necessary steps to ensure a smooth claims process. It begins with a Member Statement, where claimants must provide detailed answers to specific questions about their condition and treatment. A comprehensive list of medical providers and hospitals that treated the individual is also required, ensuring that all relevant medical history is considered. Additionally, both the Member Statement and the Authorization for Release of Information must be signed and dated. This authorization allows Pearl Carroll & Associates to gather necessary medical information to assess the claim accurately. It’s important to complete the Medical Provider’s Statement, which must be filled out by the healthcare provider overseeing the claimant's treatment. The form also emphasizes the importance of notifying Pearl Carroll immediately if the claimant recovers or returns to work, ensuring that any changes in status are promptly communicated. For those with questions or concerns about the claims process, assistance is readily available through the provided contact information. Completing the Pearl Carroll Disability Claim form accurately and thoroughly is essential for a successful application and timely benefits.
STATEMENT OF RECOVERY OR RETURN TO WORK
DISABILITY INCOME CLAIM INSTRUCTIONS
(PLEASE DETACH THIS NOTICE BEFORE MAILING AND KEEP FOR FUTURE REFERENCE)
Please answer all questions on the Member Statement on your Disability Income claim form
Please provide a complete List of Providers/Hospitals that treated you for this disability.
Date and sign both the Members Statement and the Authorization for Release of Information.
Please have your Medical Provider complete both pages of the Medical Provider’s Statement.
Please see that the completed form is returned to:
Pearl Carroll & Associates LLC
Disability Claims Unit
12 Cornell Road
Latham, NY 12110
If you recover or return to work, please notify Pearl Carroll & Associates immediately by completing and mailing this statement to the above address or emailing to Customercare@PearlCarroll.com.
If you have any questions concerning your request for Disability Income benefits, you may call the Office of the Administrator at 1-800-697-2732. The fax number is 518-640-8105. Please note that we will not confirm receipt of a fax for 24 - 48 hours.
Name: _______________________________________________________________________________
Mailing Address: _______________________________________________________________________
_______________________________________________________________________
Social Security No.: ______-______-________
Policy G-11628
I recovered:
I returned to work
Other (I.E. Returned to work light duty, another job etc):
Date:
Month/Day/Year
Date: _______________________ Signature: ___________________________________________
Email Address: __________________________________________________________________________________
CSEA DI ed 10/2016
CSEA MEMBER’S DISABILITY INCOME FORM
CLAIM TYPE:
Member Disability
Spouse-Coverage Disability
Non-Disabling Injury
Hospital Benefit
Survivor Benefit
Member Name:
____________________________________
Date of Birth: ___________________________
Social Security # _____________________________________
Male
Female
Spouse Name:
Social Security # ______________________________________
Mailing Address: _____________________________________________________________________
__________
(No.)
(Street)
(Apt No.)
_______________________________________________________________
(City or Town)
(State)
(Zip Code)
Telephone No.: Home: (
)______________________
Em ployer (
) ________________ Height: ________
Weight ________
Employer’s Name: ___________________________________________________________
Normal Number of Hours Worked Per Week: ________
Employer’s Street Address: ______________________________________________________________________________________
Email Address: ____________________________________________________________________________________________________
What is the nature of your disability?__________________________________________________________________________________
Is disability work related? Yes
No
If yes, please attach a copy of the Employee Accident Report signed by manager
Is disability due to an Injury? Yes
If “Yes”, when? _______/______/________
Mo .
Da y
Year
Where did it happen?__________________________________________________________
How did it happen? _______________________________________________________________
Date first treated for this disability:
_____/_____/_______
Mo.
Day
Date First Unable to Work: ______/______/______
Date Last Worked: ______/_______/_______
Have you attempted to return to your occupation since the date disability began? (If so, give details)
If returned to work or recovered, give date: _____/_____/______
Returned to work: Full Time:
Part Time:
If Part Time, # of hours per day _______
If not returned, when do you expect to? _____/_____/______
Are your working a second job? If so, please provide the name and address of the company and the hours you are working.
**If disability is due to a Motor Vehicle Accident, please attach MV-104A Police Report**
** If treated in hospital or Urgent Care Center, please attach a copy of your discharge papers**
1
Member’s Name ___________________________________ Member’s Social Security #________________________
Names and addresses of providers consulted and any other providers seen for treatment.
PLEASE PRINT – If you need more space, you may attach a sheet of paper with the additional names, addresses, and phone numbers. Be sure to include all providers, as any missing may delay your claim.
PHYSICIANS:
Name:
Address:
City:
State:
Zip:
Phone:
HOSPITALS
PHARMACIES
2
Member Name _______________________________________ Member’s Social Security #__________________________
Please state your occupation: ________________________________________________
**Please attach a copy of your official job description**
Please fully describe all the duties of your occupation at the time you stopped working including the percentage of time spent on
each activity:
_____________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
What are your daily activities?________________________________________________________________
_________________________________________________________________________________________________________
Are you receiving or will you be eligible to receive benefits from:
Workman’s Compensation?
Yes
Pension Plan?
Another Group Insurance Plan?
Individual Disability Income Policy?
Social Security Disability?
If “Yes” insert policy number, claim number and address of insurance company or organization providing such benefits and amount of payment.
Policy No.
Claim No.
Name and Address
Amount of Payment
I declare that the answers on Page 1, Page 2 and Page 3 of this form are complete and true to the best of my knowledge and belief. I also agree that I will advise the New York Life Insurance Company of my return to any type of work and that I will return any payments to which I am not entitled by reason of my return to work or termination of my disability.
New York Residents: Any person who knowingly and with intent to defraud any insurance company 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, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Date: _____________
Member’s Signature _______________________________________________
MO/ DAY/YEAR
The Member or someone on his/her behalf must sign here and on the
Authorization for Release of Information Form.
Please see that the completed form is returned to:
12 Cornell Road – Disability Unit
Fax # 518-640-8105 or email to Customercare@PearlCarroll.com
3
Authorization for Release of Information
TO:
All providers of medical services and supplies, pharmacy related service organizations, prescription history database
suppliers, employers, insurance institutions, the Social Security Administration and other organizations.
I authorize release to New York Life Insurance Company or their representative, Pearl Carroll & Associates LLC, any independent claim administrators, consulting health professionals, pharmacy related service organizations and utilization review organizations with whom New York Life has contracted, information concerning health care advice, treatment or supplies provided the patient (including that related to mental illness and/or AIDS/ARC/HIV) and prescription records. This information will be used to evaluate claims for benefits.
In Oklahoma, the information authorized for release may include records which may indicate the presence of a communicable or non-communicable disease.
This authorization may be used for a period of 24 months from the date signed below unless sooner revoked. I may revoke this authorization at any time by notifying New York Life in writing at the address given on this form. My revocation will not be effective to the extent New York Life or any other person has already disclosed or collected information or taken other action in reliance on it. The information New York Life obtains through this authorization may become subject to further disclosure. For example, New York Life may be required to provide it to an insurance regulatory or other government agency. In this case, the information may no longer be protected by the rules governing this authorization.
A photocopy of this authorization and request form shall be as valid as the original. I know that I may request a copy of this authorization.
_____________________________________________
_________________________________
Patient’s Signature
Date
Print Name
Social Security No
______________________________________________
__________________________________
Address
City,
State
Zip
Email Address
Phone Number
Medical Records Release to: Datafied Inc. 1210 N. Jefferson St. Suite P Anaheim, CA 92807
4
MEDICAL PROVIDER’S STATEMENT
(The patient is responsible for the completion of this form without expense to the Company)
Notice to Provider: Thank you in advance for your cooperation in completing this form on behalf of your patient identified below. We will consider this information in conjunction with other information gathered to determine the claimant’s eligibility for benefits according to his or her specific contract with us. We will periodically request that you provide updated information, records and chart notes to enable our evaluation of a continuing claim. In order for us to expedite our consideration of your patient’s claim, please fully answer each question and sign and date the form where indicated.
1.PATIENT’S NAME: ______________________________________________ SOCIAL SECURITY NO.: __________________
(First)
(Middle)
(Last)
DATE OF BIRTH: _____/_____/______
2.
CURRENT MEDICAL CONDITION(s):
(Mo) (Day)
(Year)
PRIMARY DIAGNOSIS: __________________________________
ICD-10 CM CODE: _____________
SECONDARY DIAGNOSIS: _____________________________
3.
DATE THAT SYMPTOMS FIRST APPEARED OR ACCIDENT HAPPENED:
______/_____/_______
4.
DATE THAT PATIENT FIRST CONSULTED YOU FOR THIS CONDITION:
5.
DATE YOU LAST TREATED THE PATIENT:
6.
IS THIS CONDITION RELATED TO PATIENT’S EMPLOYMENT?
YES
NO
7.
WAS PATIENT REFERRED TO YOU BY ANOTHER PRACTITIONER?
(If “Yes”, please provide the name and address of that practitioner): __________________________________________________
______________________________________________________________________________________________________________
8.OBJECTIVE FINDINGS (Include x-rays, lab results and clinical findings. If pregnancy, also give LMP and EDC):
____________________________________________________________________________________________________
9. HAS PATIENT BEEN HOSPITALIZED? YES NO (If “YES”, provide reason, hospital name and dates of
confinement): ________________________________________________________________________________
10.NATURE OF TREATMENT CURRENTLY BEING PROVIDED OR PLANNED: (Include dates and type of surgery
and any medications prescribed if applicable): ___________________________________________________
_______________________________________________________________________________________
11.HAVE YOU REFERRED THE PATIENT TO ANOTHER PRACTITIONER? YES NO (If “Yes”, please provide the name and address of all applicable physicians or ): ________________________________________________________
12.IN YOUR OPINION IS THE PATIENT ABLE TO WORK AT THIS TIME? YES NO
IF “NO”, WHEN DO YOU EXPECT THAT THE PATIENT WILL BE ABLE TO PERFORM SOME WORK?
(Mo) (Day) (Year)
PATIENT’S NAME: ______________________________________________ SOCIAL SECURITY NO.: ____________________
13.IS THERE ANY TYPE OF JOB MODIFICATION OR ACCOMODATION THAT WOULD ENABLE THE PATIENT TO WORK
AT THIS TIME? YES NO (If “Yes”, please describe): _______________________________________
14.
BASED ON OBJECTIVE FINDINGS AND YOUR
MEDICAL OPINION:
a)
THE PATIENT WAS TOTALLY DISABLED FROM:
_____/_____/_____ THROUGH: _____/_____/_____
(Mo.) (Day) (Year)
b)
THE PATIENT WAS PARTIALLY DISABLED FROM:
15.LIST ALL CURRENT RESTRICTIONS AND LIMITATIONS YOU HAVE PLACED ON THE ATIENT’S WORK AND PERSONAL
ACTIVITIES DUE TO HIS OR HER MEDICAL CONDITION (If none, indicate “NONE): ___________________________________
16. HAS THE PATIENT BEEN RELEASED FROM YOUR CARE? YES
IF “YES” DATE RELEASED FROM YOUR CARE:
IF “NO”, DATE OF NEXT SCHEDULED TREATMENT OR EVALUATION:
______/_______/________
______/_______/_________
MEDICAL PROVIDER’S DECLARATION AND SIGNATURE
I declare that the answers on this statement are complete and true to the best of my knowledge and belief. I understand that periodic updates (including providing copies of medical records when requested) will be required in the event of a continuing claim.
_______________________________________ _____
__________________
_______________________
PROVIDER’S NAME (PLEASE PRINT)
Specialty
TELEPHONE NUMBER
_________________________________________________
___________________________________________________
STREET ADDRESS
CITY
STATE
ZIP CODE
PROVIDER’S SIGNATURE
DATE SIGNED
Please return completed forms to:
Fax # 518-640-8105 or email to CustomerCare@PearlCarroll.com
Completing the Pearl Carroll Disability Claim form requires careful attention to detail. Following the instructions accurately will help ensure that your claim is processed smoothly. Below are the steps to guide you through filling out the form.
After submitting the form, it is important to notify Pearl Carroll & Associates immediately if you recover or return to work. This will help maintain transparency and ensure compliance with the terms of your claim.
What is the purpose of the Pearl Carroll Disability Claim form?
The Pearl Carroll Disability Claim form is designed to collect essential information from members seeking disability income benefits. It allows members to report their disability, provide details about their medical treatment, and outline their work history. This information is crucial for processing claims efficiently and accurately.
What information do I need to provide on the form?
Members must complete several sections of the form, including personal details such as name, address, and Social Security number. Additionally, it requires information about the nature of the disability, treatment providers, and the member's work history. A complete list of medical providers and hospitals that treated the member for the disability is also necessary.
How should I submit the completed claim form?
Once the form is completed, it should be mailed to the Pearl Carroll & Associates LLC Disability Claims Unit at 12 Cornell Road, Latham, NY 12110. Alternatively, members can fax the form to 518-640-8105 or email it to Customercare@PearlCarroll.com. It is important to keep a copy for your records.
What should I do if I recover or return to work?
If a member recovers or returns to work, it is essential to notify Pearl Carroll & Associates immediately. This can be done by completing the Statement of Recovery or Return to Work section of the claim form and submitting it through the same channels as the original claim.
What if I have questions while filling out the form?
If any questions arise during the completion of the form, members are encouraged to contact the Office of the Administrator at 1-800-697-2732. Assistance is available to ensure that all necessary information is provided accurately.
Is there a deadline for submitting the claim form?
While specific deadlines may vary, it is advisable to submit the claim form as soon as possible after the disability begins. Prompt submission helps avoid delays in processing and ensures that benefits can be provided in a timely manner.
What happens if I do not provide all required information?
Failure to provide complete and accurate information may lead to delays in processing the claim. It is vital to include all requested details, including the names and addresses of all medical providers, to avoid complications.
Can I authorize someone else to submit the claim on my behalf?
Yes, a member can authorize another individual to submit the claim on their behalf. However, the member must still sign the form, and the authorized individual must provide their information as well. It is important to ensure that the person assisting you is trusted and understands the details of your claim.
What should I do if my claim is denied?
If a claim is denied, members should carefully review the denial letter for specific reasons. It may be beneficial to gather additional documentation or clarification from medical providers and submit an appeal. Contacting the claims unit for guidance on the appeals process is also recommended.
Filling out the Pearl Carroll Disability Claim form can be a daunting task. Many individuals make common mistakes that can delay the processing of their claims. One significant error is failing to answer all questions on the Member Statement. Each question is designed to gather essential information. Omitting even one can lead to unnecessary delays.
Another frequent mistake involves not providing a complete list of healthcare providers and hospitals that treated the individual for their disability. This information is crucial for verifying the claim. Missing names or contact details can hinder the claim's progress. It is essential to include every provider to avoid complications.
Many applicants forget to date and sign both the Member Statement and the Authorization for Release of Information. These signatures confirm the accuracy of the information provided. Without them, the claim may be considered incomplete. Ensuring that both documents are signed and dated is vital.
Additionally, some individuals neglect to have their medical provider complete both pages of the Medical Provider’s Statement. This step is critical for the evaluation of the claim. Incomplete medical documentation can lead to delays or even denials of benefits.
Another common oversight is failing to notify Pearl Carroll & Associates promptly if there is a recovery or return to work. Immediate communication is necessary to update the claim status. Not doing so can result in complications regarding benefit payments.
Some claimants also overlook the requirement to attach necessary documentation, such as police reports for motor vehicle accidents or hospital discharge papers. These documents are often vital for substantiating the claim. Without them, the claim may not be processed efficiently.
Another mistake involves providing insufficient details about the nature of the disability. Claimants should be clear and thorough in describing their condition. Vague descriptions can lead to misunderstandings and delays in the claim process.
Lastly, individuals often forget to include their occupation details, including a job description and the percentage of time spent on various activities. This information helps assess the impact of the disability on their work life. Omitting these details can hinder the evaluation process.
The Pearl Carroll Disability Claim form is a crucial document for individuals seeking disability income benefits. Along with this form, several other documents may be required to support the claim. Below is a list of commonly used forms and documents that accompany the claim process.
Collecting and submitting these documents along with the Pearl Carroll Disability Claim form can significantly enhance the chances of a successful claim. Each document plays a vital role in providing a complete picture of the claimant's situation and medical history.
Do's and Don'ts for Filling Out the Pearl Carroll Disability Claim Form
While the form may appear lengthy, it is designed to gather essential information to process your claim efficiently. Each section serves a specific purpose, ensuring that all necessary details are captured. Taking your time to fill it out accurately will help streamline the process.
It's a common belief that only the medical provider's signature is required. However, the member must also sign the form. This signature confirms that the information provided is accurate and complete, which is crucial for the claim's validity.
Regardless of the nature of your return to work, it is essential to notify Pearl Carroll & Associates. This includes part-time or light-duty positions. Failing to do so may affect your benefits and could lead to complications in your claim.
Some may think that they can submit the claim without providing a full list of all medical providers involved in their treatment. However, omitting any providers can delay the processing of your claim. It's vital to include every provider to avoid unnecessary setbacks.
Complete all sections of the Member Statement on the Disability Income claim form. This ensures that your application is processed without unnecessary delays.
List all providers and hospitals that treated you for your disability. Providing comprehensive information helps streamline your claim.
Sign and date both the Member Statement and the Authorization for Release of Information. This is crucial for your claim to be valid.
Ensure your Medical Provider fills out both pages of the Medical Provider’s Statement. Their input is essential for verifying your condition.
Return the completed form to Pearl Carroll & Associates at the specified address. This ensures it reaches the right department for processing.
If you recover or return to work, notify Pearl Carroll & Associates immediately. This can be done by mailing the relevant statement or emailing them directly.
Contact the Office of the Administrator if you have questions about your Disability Income benefits. They can provide guidance and clarification.
Be aware that if you fax your documents, confirmation of receipt may take 24 to 48 hours. Plan accordingly to avoid any issues with your claim.