The Pearl Carroll Disability Claim form is designed for individuals seeking to report their recovery or return to work while receiving disability income benefits. This comprehensive document requires detailed information about the claimant's medical providers, workplace, and the nature of their disability, along with a signed authorization for the release of medical information. By accurately completing and submitting this form, claimants can ensure the proper management of their disability benefits. Ready to start? Click the button below to fill out your form.
The journey of navigating through a disability claim can often feel like you're trying to find your way through a maze. For members encountering this process with Pearl Carroll & Associates LLC, the Pearl Carroll Disability Claim form serves as a vital tool in this journey, meticulously guiding you from the statement of recovery to the eventual return to work. The form requires a thorough detailing of the member's personal information, including but not limited to the nature of the disability, treatments received, and work status. It places significant emphasis on the submission of a comprehensive list of medical providers that have treated the member, alongside a requirement for the member and their medical provider to fill out and sign specific sections of the form. Additionally, an Authorization for Release of Information section mandates consent from the individual, enabling the seamless sharing of medical and other relevant data that supports their claim. Such detailed provisions are crafted to ensure that the process is as smooth and as efficient as possible, ensuring that individuals are neither left in the dark nor without aid in their time of need. Therefore, whether one is mailing the completed form to the designated address in Latham, NY, or engaging through email or fax, Pearl Carroll & Associates LLC delineates a structured path towards the resolution of disability claims, simultaneously underscoring their commitment to client assistance and the expeditious handling of such sensitive and crucial matters.
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
Filling out the Pearl Carroll Disability Claim Form is a crucial step in requesting disability income benefits. This document requires accurate and detailed information about your health condition, treatment history, and work status. By following the steps outlined below, you ensure that your claim is processed efficiently. Remember, providing complete and honest information is vital to the success of your claim. Once the form is filled out, it needs to be returned to Pearl Carroll & Associates, making sure to notify them of any changes in your recovery or employment status.
After submitting the form, it's important to stay in contact with Pearl Carroll & Associates, especially if there are updates or changes to your situation. Keep a copy of all documents for your records, and don't hesitate to reach out to their office if you have any questions during the process.
To properly complete the Pearl Carroll Disability Claim form, you must:
Don't forget to detach the instructions before mailing your form and keep them for your reference.
If you recover or return to work, promptly notify Pearl Carroll & Associates by completing and mailing the statement provided in the instructions to the specified address or by emailing it to the provided address. This helps ensure that your claim is accurately processed according to your current employment status.
If you have any questions regarding your request for Disability Income benefits, feel free to call the Office of the Administrator at 1-800-697-2732 or send a fax to 518-640-8105. However, please note that fax receipt confirmations may take 24 - 48 hours.
When explaining your disability on the claim form, include:
Additionally, attach any relevant documents, such as an MV-104A Police Report for motor vehicle accidents or discharge papers if treated in a hospital or Urgent Care Center.
On the designated page of the claim form, list all providers, including doctors, hospitals, and pharmacies, that have seen or treated you for your disability. Ensure to print clearly and provide complete names, addresses, and phone numbers for each provider. If you need additional space, attach a separate sheet with the required information. Missing details could delay your claim processing.
If your disability is related to your occupation, you must:
The Authorization for Release of Information allows New York Life Insurance Company or their representative, Pearl Carroll & Associates LLC, to obtain necessary information to evaluate your claim for benefits. This authorization is valid for 24 months from the date signed and can be revoked at any time by notifying New York Life in writing. However, revocation will not affect any action already taken based on the consent given. It's also important to remember that once information is disclosed, it may become subject to further disclosure, such as to regulatory or government agencies.
When filling out the Pearl Carroll Disability Claim form, individuals often make several common errors that can delay the processing of their claim. These mistakes can be minimized or avoided altogether with careful attention to detail and adherence to the provided instructions. Below are five common mistakes made during this process.
Failing to Answer All Questions: The form explicitly requests that all questions be answered on the Member Statement. Omission of information can lead to incomplete submissions, requiring further communication and prolonging the evaluation period. It's crucial to review the form multiple times to ensure that no question has been left unanswered.
Inadequate Provider Information: Providing a complete list of providers/hospitals that treated the disability is essential. Many claimants either submit incomplete lists or forget to include key healthcare providers. This oversight can result in delays as the insurance company may need to verify treatment details or gather additional information to assess the claim properly.
Insufficient Documentation: The claim form asks for various documentation, such as attaching a copy of the Employee Accident Report if the disability is work-related or including discharge papers for hospital or urgent care center treatment. Failing to attach these documents can hinder the verification process, requiring the insurance company to follow up for additional evidence, thereby extending the processing time.
Incorrectly Signing Documents: The form requires the claimant's signature on both the Member's Statement and the Authorization for Release of Information. Overlooking these signature requirements or improperly filling out these sections can invalidate the submission until properly corrected and resubmitted. Accuracy in these areas is paramount to advancing the claim.
Delay in Notification of Recovery or Return to Work: The instructions explicitly state that if a claimant recovers or returns to work, they must notify Pearl Carroll & Associates immediately. Delayed notifications not only complicate the claim process but can also lead to issues of overpayment, in which the claimant may have to return funds to the insurer. Prompt communication upon return to work or recovery ensures the integrity of the process and avoids financial discrepancies.
By carefully navigating these common pitfalls, individuals submitting a disability claim to Pearl Carroll & Associates can improve the efficiency and outcome of their claim processing. Attention to detail and adherence to the instructions are critical steps toward achieving a favorable resolution.
When filing a Pearl Carroll Disability Claim, it's essential to gather and include all necessary documents to ensure your claim is processed quickly and efficiently. These documents provide a comprehensive picture of your situation and substantiate your claim for disability benefits. Here’s an outline of other forms and documents often used alongside the Pearl Carroll Disability Claim form.
Filing for disability benefits requires careful documentation to successfully prove the nature and extent of your disability. Including these forms and documents with your Pearl Carroll Disability Claim can help streamline the process, ensuring that you receive the support you're entitled to during your time of need.
The Long-Term Disability (LTD) Claim Form exhibits notable similarities to the Pearl Carroll Disability Claim form, particularly in its structured solicitation of comprehensive personal, occupational, and medical information from the claimant. Both documents require detailed accounts of the claimant's condition, the onset and extent of the disability, alongside a thorough medical history including treatment and provider details. These aspects are integral to the assessment and determination process of disability claims.
Another related document is the Workers' Compensation Claim Form. This form shares the Pearl Carroll form's requirement for specifying whether the disability is work-related, alongside details of the incident that led to the disability. Both documents also necessitate information about the claimant's employment status and job responsibilities, highlighting the contextual examination of the claimant’s work environment and its potential role in the disability.
The Social Security Disability Benefits Application has parallels with the Pearl Carroll Disability Claim form in its comprehensive approach to gathering the claimant's personal and medical information. Key similarities include requiring the claimant’s work history, the impact of the disability on their employment capacity, and detailed medical provider information for verification purposes. However, the Social Security application places greater emphasis on the claimant's work credits and eligibility under federal guidelines.
Lastly, the Individual Disability Income Policy Claim Form often found in private insurance, matches closely with the structure seen in the Pearl Carroll form. It mandates exhaustive personal, employment, and medical details from the claimant to substantiate the claim. This includes documentation of the disability’s onset, progression, and treatment, parallel to the detailed provider list and authorization for the release of medical information found in the Pearl Carroll document.
When completing the Pearl Carroll Disability Claim form, it is essential to follow specific guidelines to ensure your claim is handled efficiently and without unnecessary delay. Below is a list of suggested dos and don'ts:
Adhering to these guidelines can facilitate a smoother claim process, minimizing potential delays and improving the likelihood of a favorable outcome. Always remember to review your claim forms for accuracy before submission and reach out to the administrators if clarification is needed on any points.
When filing a disability claim with Pearl Carroll & Associates, people often encounter misconceptions that can affect their applications. Understanding these misconceptions can help ensure that the claims process goes smoothly.
All questions on the claim form are optional. It's a common belief that not all questions need to be answered when filling out the disability claim form. However, it is crucial to answer all questions on the Member Statement to avoid any delays in processing your claim. Complete information helps Pearl Carroll & Associates accurately assess your situation.
Medical provider statements are not necessary if you provide a list of providers. Another misconception is that simply listing your providers or hospitals is sufficient. In reality, having your Medical Provider complete both pages of the Medical Provider’s Statement is crucial for a comprehensive review of your claim. This detailed information cannot be replaced by a list of providers.
You only need to notify Pearl Carroll & Associates once you have fully recovered. It's important to inform Pearl Carroll & Associates not just when you’ve fully recovered, but also if you return to work in any capacity. This includes returning to work on a light duty basis, taking up another job, or any change in your work situation related to your disability.
The claim process is complete once you submit your documents. Filing your claim does not mark the end of the process. Pearl Carroll & Associates may require additional information or clarifications to process your claim. Also, remember that it will not confirm receipt of a faxed submission for 24-48 hours, so immediate confirmation should not be expected.
Providing your social security number is optional. While sharing personal information like your social security number can feel uncomfortable, it is essential for processing your disability income claim. Pearl Carroll & Associates needs this information to verify your identity and to ensure that your claim is handled efficiently.
Dispelling these misconceptions can make the process of submitting a disability claim to Pearl Carroll & Associates smoother and more efficient. Remember to carefully read and follow all instructions provided with the claim form to avoid any unnecessary delays or issues.
Understanding the process for submitting a Pearl Carroll Disability Claim is crucial for ensuring timely and accurate processing of your claim. Here are five key takeaways to keep in mind:
By following these guidelines and ensuring all documentation is filled out completely and accurately, you can help facilitate a smoother claim process with Pearl Carroll & Associates.
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