Robin Denham Taylor

Experienced in fostering strong client relationships through effective communication. Excels in delivering personalized patient care to ensure optimal well-being and happiness. Dedication extends to supporting families during challenging times, enhancing overall patient experience. Continuously updating medical expertise to deliver top-notch care and stay abreast of industry advancements.

CNA and current BLS

• AMERICAN HERITAGE LIFE INSURANCE COMPANY
• ATTENDING PHYSICIAN'S STATEMENT
• Submit Claims: Online at: www.allstatebenefits.com by Fax to 1-866-424-8482 or by
• Mail to: American Heritage Life Insurance Company 1776 American Heritage Life Drive, Jacksonville, FL 32224
• For Claim Assistance, please contact our Customer Care Center at 1-800-521-3535
• CLAIMANT'S NAME: DATE OF BIRTH:
• COVERAGE NUMBER(S): CLAIM NUMBER:
• ATTENDING PHYSICIAN'S STATEMENT: To be completed by the attending physician. This form is for Accident, Hospital Indemnity (SHOP/GIM), Critical Illness, Cancer, Heart and Stroke, and Disability Claims.
• SECTION #1: DESCRIBE THE CONDITION – FOR ALL CLAIMS:
• ICD 9/10 Code: Primary Diagnosis:
• ICD 9/10 Code: Secondary Diagnosis:
• Other Condition(s):
• When did symptoms first appear? If applicable, what was the accident date?
• Has the patient ever had the same/similar condition? Yes No If yes, when?
• Is the condition due to injury or sickness arising out of the patient’s employment? Yes No
• Pregnancy or Complication of Pregnancy: Due Date: Delivery Date: Normal Delivery C-Section
• SECTION #2: TREATMENT REQUIRED – FOR ALL CLAIMS:
• First consultation: Most recent consultation: Next consultation: Released:
• Is/was diagnostic testing performed? Yes No Test(s): Dates:
• Results:
• Is/was a surgical or medical procedure required? Yes No Date: Procedure Code:
• Procedure:
• Is/was hospitalization required? Yes No Admission Date: Discharge Date:
• Hospital: City: State:
• What is the current treatment plan?
• SECTION #3: RESTRICTIONS, LIMITATIONS AND ABILITY TO WORK – FOR DISABILITY AND WAIVER OF PREMIUM CLAIMS:
• Please provide specific details and dates. Responses such as “no work”, “totally disabled”, “undetermined” or “unknown” will not enable us to evaluate your patient’s claim for benefits and may result in us having to contact you for clarification
• The patient is able to work in the following capacity: No Work Sedentary Light Medium Heavy Very Heavy
• The patient is unable to perform their job duties? Yes No If yes, please provide the dates from: through:
• When is the patient expected to resume part time/partial duties: full time/full duties:
• The patient is unable to: Stand Hours; Sit Hours; Walk Hours; Lift Pounds; Carry Pounds; Drive Hours;
• Perform Data Entry Reach Kneel Squat Climb Crawl
• Please provide the specific restrictions:
• Please provide the specific limitations:
• The restrictions and limitations are: Temporary (If so, how long? ) Permanent
• What clinical or diagnostic findings support these restrictions and limitations?
• SECTION #4: REFERRING PHYSICIAN – FOR ALL CLAIMS:
• Name: Specialty:
• Address: Phone #:
• SECTION #5: ATTENDING PHYSICIAN VERIFICATION – FOR ALL CLAIMS:
• I am aware that it is a crime to fill out this form with facts I know are false or to leave out facts I know are relevant and important. I certify that the answers given on this form are true, complete and correctly recorded.
• Physician Signature: Date:
• Print Name: Specialty: Phone #:
• Address: City: State: Zip Code:
• Remember it is a crime to fill out this form with facts you know are false or to leave out facts you know are relevant and important. Please check to be sure all information is correct before signing. Please refer to the fraud notice specific to your state.
• ABJ21382-2 Page 1 of 2 (11/20)

• AMERICAN HERITAGE LIFE INSURANCE COMPANY
• ATTENDING PHYSICIAN'S STATEMENT
• Submit Claims: Online at: www.allstatebenefits.com by Fax to 1-866-424-8482 or by
• Mail to: American Heritage Life Insurance Company 1776 American Heritage Life Drive, Jacksonville, FL 32224
• For Claim Assistance, please contact our Customer Care Center at 1-800-521-3535
• FRAUD WARNING BY STATE
• NOTICE IN ALASKA, ARKANSAS, KENTUCKY, LOUISIANA, MAINE, NEW JERSEY, NEW MEXICO, AND VIRGINIA: Any person who knowingly and with intent to injure, defraud or deceive an insurance company files a claim containing false, incomplete or misleading information may be prosecuted under state law.
• NOTICE IN DELAWARE, IDAHO, INDIANA, MINNESOTA, AND OKLAHOMA: Any person who knowingly and with intent to injure, defraud or deceive an insurance company files a claim containing false, incomplete or misleading information is guilty of a felony.
• NOTICE IN ARIZONA: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
• NOTICE IN CALIFORNIA: For your protection, California law requires the following to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
• NOTICE IN COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.
• NOTICE IN DISTRICT OF COLUMBIA: FRAUD NOTICE: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant.
• NOTICE IN FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
• NOTICE IN MARYLAND: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
• NOTICE IN NEW HAMPSHIRE: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.
• NOTICE IN OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
• NOTICE IN OREGON: Any person who makes intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law.
• NOTICE IN PENNSYLVANIA: 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 subjects such person to criminal and civil penalties.
• NOTICE IN PUERTO RICO: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or file, assist or abet in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years.
• NOTICE IN TENNESSEE AND WASHINGTON: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
• NOTICE IN TEXAS: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
• NOTICE IN WEST VIRGINIA AND RHODE ISLAND: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and imprisonment.
• Remember it is a crime to fill out this form with facts you know are false or to leave out facts you know are relevant and important. Please check to be sure all information is correct before signing. Please refer to the fraud notice specific to your state.
• ABJ21382-2 Page 2 of 2 (11/20)