{"id":51,"title":"ATTENDING PHYSICIAN'S STATEMENT FOR CRITICAL ILLNESS","purpose":"claim","insurer":{"slug":"bandhan-life-insurance","name":"Bandhan Life Insurance Limited"},"source_pdf":"https://www.bandhanlife.com/sites/default/files/asset/2026-04/Attending%20Physician%20Statement%20-%20Critical%20Illness.pdf","sha256":"42522a4a44f58282719918655715aca17ac64cefa8f6e0fcd7fde43ce20db0fe","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is to be completed by the attending physician who treated the life assured during their critical illness to provide medical details for a critical illness claim.","notes":["A policyholder or life insured who is a medical practitioner, or their spouse or near relative who is a medical practitioner, is not allowed to fill this form."],"title":"ATTENDING PHYSICIAN'S STATEMENT FOR CRITICAL ILLNESS","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Part I - General Information","fields":[{"help":"","type":"text","label":"Name of the patient","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you the patient's usual doctor? If \"yes\", please give the following details.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter number of years","type":"number","label":"Since when have you known the patient","options":[],"required":null,"pdf_field":""},{"help":"Specify relationship if applicable","type":"text","label":"Is the patient related to you? If yes, how?","options":[],"required":null,"pdf_field":""},{"help":"Provide dates of consultations","type":"text","label":"Dates of consultation","options":[],"required":null,"pdf_field":""},{"help":"Provide diagnosis details","type":"text","label":"Diagnosis arrived at","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the patient referred to you by another doctor or hospital? If \"Yes\", please state:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If referred, provide name","type":"text","label":"Name of doctor/ hospital","options":[],"required":null,"pdf_field":""},{"help":"If referred, provide address and contact","type":"text","label":"Address & contact number of doctor/hospital","options":[],"required":null,"pdf_field":""},{"help":"Patient's age","type":"number","label":"Age","options":[],"required":null,"pdf_field":""}],"filled_by":"attending physician"},{"title":"Part II - Details of the illness complained","fields":[{"help":"Describe illness and diagnosis; attach original reports if applicable","type":"text","label":"Please fully describe the nature of illness and the Diagnosis- (Please attach original reports where applicable).","options":[],"required":null,"pdf_field":""},{"help":"Provide date and details of first symptoms","type":"text","label":"Date and details of first symptoms","options":[],"required":null,"pdf_field":""},{"help":"Provide relevant past medical history","type":"text","label":"Details of past history","options":[],"required":null,"pdf_field":""},{"help":"List investigations and lab tests","type":"text","label":"Investigations done/ advised to be done / laboratory tests undergone","options":[],"required":null,"pdf_field":""},{"help":"Describe treatment given","type":"text","label":"Details of Treatment Given: Medical/surgical/ Hospitalization/Conservative","options":[],"required":null,"pdf_field":""},{"help":"Provide final diagnosis with reports","type":"text","label":"Final Diagnosis (please include any specialist/lab reports)","options":[],"required":null,"pdf_field":""},{"help":"Provide surgery details and date","type":"text","label":"If surgery performed, please describe fully the date on which it was performed and the nature of the surgery","options":[],"required":null,"pdf_field":""},{"help":"Mention other diseases affecting condition","type":"text","label":"Describe any other disease or infirmity affecting present condition.","options":[],"required":null,"pdf_field":""}],"filled_by":"attending physician"},{"title":"Follow up Details","fields":[{"help":"Provide last attendance date","type":"date","label":"When was the date of last attendance at the hospital","options":[],"required":null,"pdf_field":""},{"help":"Provide current care details if applicable","type":"text","label":"Is the patient still under your care for this condition? If so please give details.","options":[],"required":null,"pdf_field":""},{"help":"Optional additional information","type":"text","label":"Any additional information you would prefer to share.","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the patient referred to any other doctor or medical facility by you? If Yes please provide details.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If referred, provide name","type":"text","label":"Name of doctor/ hospital","options":[],"required":null,"pdf_field":""},{"help":"If referred, provide address and contact","type":"text","label":"Address & contact number of doctor/hospital","options":[],"required":null,"pdf_field":""},{"help":"Provide hospital name and address","type":"text","label":"In case of hospitalization, please give name and address of hospital:","options":[],"required":null,"pdf_field":""},{"help":"Provide admission date","type":"date","label":"Date admitted","options":[],"required":null,"pdf_field":""},{"help":"Provide discharge date","type":"date","label":"Date discharged","options":[],"required":null,"pdf_field":""},{"help":"Provide prognosis details","type":"text","label":"What is the prognosis?","options":[],"required":null,"pdf_field":""},{"help":"Optional additional information","type":"text","label":"Any other information, which in your opinion will assist us in assessing this claim","options":[],"required":false,"pdf_field":""}],"filled_by":"attending physician"},{"title":"Physician's Declaration and Signature","fields":[{"help":"","type":"text","label":"Name of physician","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Date of signing with official stamp","type":"date","label":"Date (With stamp)","options":[],"required":true,"pdf_field":""},{"help":"Physician's qualification","type":"text","label":"Qualification","options":[],"required":true,"pdf_field":""},{"help":"Physician's address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Physician's contact number","type":"phone","label":"Telephone No:","options":[],"required":false,"pdf_field":""}],"filled_by":"attending physician"}],"deadlines":[],"applies_to":"critical illness claims under the policy","attachments":["original reports where applicable"],"declarations":["I hereby certify that I have personally examined and treated the patient for the above illness.","The details given are based on records and my assessment of the facts."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"submit duly completed claim forms and other documents at the nearest Bandhan Life Branch Office or at our Head Office","label":"Claim Intimation and Registration","level":null,"hours":null,"applies_to":"life","source_url":"https://www.bandhanlife.com/customer-service/claims-process","quote":"nes can use the amount when they need it most.\nClaim Intimation and Registration\nFor Claims intimation to Bandhan Life, submit duly completed claim forms and other documents at the nearest Bandhan Life Branch Office or at our Head Office. Please click on the below links to see/ download the requirement list, claim forms and to locate our nearest branch of","fetched_at":"2026-10-20"}],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/bandhan-life-insurance/51-attending-physician-s-statement-for-critical-illness"}