LTD STD Claim Physicians Statement

Dx Disability Claims Attending Physician Statement Use this form to provide us with the information we need from you and your physician to process your claim for disability benefits. Metropolitan Life Insurance Company Things to Know Before You Begin • You should complete and sign Section 1 of this form before giving it to your physician. If the form is sent directly to your physician, you may have your physician complete Section 1 for you. Section 2 MUST be completed by your physician. • Submitting an incomplete form may delay processing your claim. • Some physicians may charge for completion of this form. Any such charge is your responsibility. • New York: 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 Please write the claim number on subject to a civil penalty not to exceed five thousand dollars and any additional documents you the stated value of the claim for each such violation. send. SECTION 1: Claim Information (To be completed by the person submitting the claim, or by the physician if received directly.) Claimant First Name Middle Name Last Name Date of Birth (mm/dd/yyyy) Customer Name Occupation Physician First Name Last Name Physician Phone Number Claim Number Authorization For Physician to Share My Medical Information I authorize my physician to release to MetLife Disability any information collected in the course of examining or treating me as a patient. Claimant Signature Date (mm/dd/yyyy) APS-STDLTD-5320 (06/20) Page 1 of 7