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Fill in Your Pearl Carroll Disability Claim Template

The Pearl Carroll Disability Claim form is a document used to apply for disability income benefits. This form requires detailed information about your medical condition, treatment providers, and work history. Completing it accurately is essential for a smooth claims process.

Table of Contents

The Pearl Carroll Disability Claim form is an essential tool for individuals seeking to secure disability income benefits. This comprehensive form guides users through a series of important steps to ensure that their claims are processed smoothly and efficiently. It requires claimants to provide detailed information about their medical condition, including a complete list of healthcare providers and hospitals that have treated them. Additionally, it asks for a clear description of the nature of the disability and whether it is work-related. Claimants must also document their employment history, including the dates they were unable to work and any attempts to return to their job. To facilitate the claims process, both the member and their medical provider must complete specific sections of the form, ensuring that all necessary information is gathered. Furthermore, the form emphasizes the importance of notifying Pearl Carroll & Associates promptly if the claimant recovers or returns to work, reinforcing the need for open communication throughout the claims process. By adhering to these guidelines, individuals can navigate the complexities of filing a disability claim with confidence.

Sample - Pearl Carroll Disability Claim Form

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 [email protected].

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:	____________________________________					Date of Birth: ___________________________
Social Security # ______________________________________							Male	Female
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: ______________________________________________________________________________________
		(No.)		(Street)			(City or Town)		(State)	(Zip Code)

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		No		If “Yes”, when? _______/______/________
						Mo .	Da y	Year
Where did it happen?__________________________________________________________
How did it happen? _______________________________________________________________
Date first treated for this disability:		_____/_____/_______
		Mo.	Day	Year
Date First Unable to Work: ______/______/______				Date Last Worked: ______/_______/_______
Mo.	Day	Year		Mo.	Day	Year

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:
Mo.	Day	Year	Part Time:
			If Part Time, # of hours per day _______
If not returned, when do you expect to? _____/_____/______
Mo.	Day	Year

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**

CSEA DI ed 10/2016

CSEA MEMBER’S DISABILITY INCOME FORM

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:			Name:

Address:			Address:

City:			City:

State:	Zip:		State:	Zip:

Phone:			Phone:

Name:			Name:

Address:			Address:

City:			City:

State:	Zip:		State:	Zip:

Phone:			Phone:

Name:			Name:

Address:			Address:

City:			City:

State:	Zip:		State:	Zip:

Phone:			Phone:

		HOSPITALS
Name:			Name:

Address:			Address:

City:			City:

State:	Zip:		State:	Zip:

Phone:			Phone:

		PHARMACIES
Name:			Name:

Address:			Address:

City:			City:

State:	Zip:		State:	Zip:

Phone:			Phone:

CSEA DI ed 10/2016

CSEA MEMBER’S DISABILITY INCOME FORM

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	No
	Pension Plan?	Yes	No
	Another Group Insurance Plan?	Yes	No
	Individual Disability Income Policy?	Yes	No
	Social Security Disability?	Yes	No

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:
	Pearl Carroll & Associates LLC
	12 Cornell Road – Disability Unit
	Latham, NY 12110
	Fax # 518-640-8105 or email to [email protected]
	3

CSEA DI ed 10/2016

	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

Please see that the completed form is returned to:

Pearl Carroll & Associates LLC

12 Cornell Road – Disability Unit

Latham, NY 12110

Fax # 518-640-8105 or email to [email protected]

CSEA DI ed 10/2016

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: _____________________________			ICD-10 CM CODE: _____________
3.	DATE THAT SYMPTOMS FIRST APPEARED OR ACCIDENT HAPPENED:				______/_____/_______
					(Mo) (Day)	(Year)
4.	DATE THAT PATIENT FIRST CONSULTED YOU FOR THIS CONDITION:				______/_____/_______
					(Mo) (Day)	(Year)
5.	DATE YOU LAST TREATED THE PATIENT:				______/_____/_______
					(Mo) (Day)	(Year)
6.	IS THIS CONDITION RELATED TO PATIENT’S EMPLOYMENT?			YES	NO
7.	WAS PATIENT REFERRED TO YOU BY ANOTHER PRACTITIONER?			YES	NO

(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)

CSEA DI ed 10/2016

MEDICAL PROVIDER’S STATEMENT

PATIENT’S NAME: ______________________________________________ SOCIAL SECURITY NO.: ____________________

(First)

(Middle)

(Last)

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)	(Mo.) (Day) (Year)
b)	THE PATIENT WAS PARTIALLY DISABLED FROM:	_____/_____/_____ THROUGH: _____/_____/_____
		(Mo.) (Day) (Year)	(Mo.) (Day) (Year)

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			NO
IF “YES” DATE RELEASED FROM YOUR CARE:		IF “NO”, DATE OF NEXT SCHEDULED TREATMENT OR EVALUATION:
______/_______/________			______/_______/_________
(Mo) (Day)	(Year)		(Mo) (Day)	(Year)

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:

Pearl Carroll & Associates LLC

12 Cornell Road – Disability Unit

Latham, NY 12110

Fax # 518-640-8105 or email to [email protected]

CSEA DI ed 10/2016

↓ Pearl Carroll Disability Claim PDF

File Specs

Fact Name	Description
Claim Submission	The Pearl Carroll Disability Claim form must be completed in full, including the Member Statement and the Medical Provider’s Statement.
Provider Information	A complete list of all healthcare providers and hospitals involved in the treatment of the disability must be included to avoid delays in processing the claim.
Notification of Recovery	If the claimant recovers or returns to work, they must notify Pearl Carroll & Associates immediately, using the provided methods of communication.
Governing Law	This form is governed by New York State law, which includes regulations regarding the submission of disability claims and the penalties for fraudulent claims.

Pearl Carroll Disability Claim - Usage Guidelines

Filling out the Pearl Carroll Disability Claim form requires careful attention to detail to ensure that all necessary information is provided. This process involves several steps that must be followed to complete the form accurately. Below are the instructions to guide you through the completion of the form.

Begin by filling out the Member Statement section. Provide your full name, mailing address, and Social Security number.
Indicate your claim type by selecting from options such as Member Disability, Spouse-Coverage Disability, Non-Disabling Injury, Hospital Benefit, or Survivor Benefit.
Provide details about your disability, including its nature, whether it is work-related, and any relevant dates such as when you first treated the disability and when you last worked.
List all medical providers and hospitals that treated you for the disability. Include names, addresses, and phone numbers. If necessary, attach additional sheets for more providers.
Complete the section about your occupation, including a description of your job duties and the percentage of time spent on each activity. Attach your official job description.
Answer questions regarding any other benefits you may be receiving, such as Workers' Compensation or Social Security Disability. Include policy numbers and amounts if applicable.
Review all the information you have provided for accuracy. Ensure that all questions are answered, and all required sections are completed.
Sign and date the Member Statement and the Authorization for Release of Information at the designated places.
Return the completed form to Pearl Carroll & Associates LLC at the specified address. You may also fax or email the form as instructed.

After submitting the form, you may want to keep a copy for your records. If your condition changes or you return to work, it is essential to notify Pearl Carroll & Associates promptly. Should you have any questions during the process, reaching out to their office can provide you with the necessary assistance.

Your Questions, Answered

What is the purpose of the Pearl Carroll Disability Claim form?

The Pearl Carroll Disability Claim form is designed to collect necessary information from individuals applying for disability income benefits. It gathers details about the claimant's disability, treatment history, and work status, allowing Pearl Carroll & Associates to process claims efficiently.

What information must be provided on the Member Statement?

The Member Statement requires claimants to answer all questions thoroughly. This includes personal details such as name, address, Social Security number, and specifics about the disability, including the nature of the disability, treatment history, and any attempts to return to work.

How should I submit the completed form?

The completed Pearl Carroll Disability Claim form should be mailed to Pearl Carroll & Associates LLC at the specified address: 12 Cornell Road, Latham, NY 12110. Alternatively, it can be sent via email to [email protected]. Ensure that all required signatures are included before submission.

What should I do if I recover or return to work?

If you recover or return to work, it is essential to notify Pearl Carroll & Associates immediately. This can be done by completing the statement provided in the form and mailing it to the address mentioned above or emailing it to the customer care email address.

What if I have questions about my disability claim?

If you have questions regarding your request for Disability Income benefits, you can contact the Office of the Administrator at 1-800-697-2732. They can provide assistance and clarify any doubts you may have about the claims process.

Are there specific documents that need to be attached to the claim form?

Yes, claimants should attach any relevant documents that support their claim. This includes a copy of the Employee Accident Report if the disability is work-related, discharge papers if treated in a hospital or urgent care center, and any other necessary medical documentation that may assist in processing the claim.

What happens if I do not include all providers in my claim?

It is crucial to provide a complete list of all medical providers and hospitals that treated you for the disability. Missing information may delay the processing of your claim. If additional space is needed, claimants can attach a separate sheet with the required details.

What is the significance of the Authorization for Release of Information?

The Authorization for Release of Information allows Pearl Carroll & Associates to obtain necessary medical records and information from healthcare providers. This authorization is vital for evaluating claims for benefits and must be signed and dated by the claimant.

Common mistakes

Failing to answer all questions on the Member Statement. Every question must be addressed to avoid delays.
Not providing a complete list of healthcare providers or hospitals. Missing names can slow down the claims process.
Neglecting to date and sign both the Member Statement and the Authorization for Release of Information. This step is crucial for processing your claim.
Forgetting to have your Medical Provider complete both pages of the Medical Provider’s Statement. Incomplete forms can lead to complications.
Not notifying Pearl Carroll & Associates immediately if you recover or return to work. This is important for maintaining compliance.
Omitting details about the nature of your disability. Be specific to provide a clearer understanding of your situation.
Failing to attach required documents, such as the Employee Accident Report for work-related injuries. This documentation is essential.
Not providing your complete mailing address. Ensure all parts of your address are included for effective communication.
Overlooking to describe daily activities accurately. This information helps to assess the impact of your disability.
Not keeping a copy of the completed form for your records. Having a copy can be helpful for future reference.

Documents used along the form

When filing a disability claim with Pearl Carroll, several additional forms and documents may be required to support your application. Each of these documents plays a crucial role in ensuring that your claim is processed efficiently and accurately. Below is a list of commonly used forms that accompany the Pearl Carroll Disability Claim form.

Member Statement: This is a key component of your disability claim. It requires you to provide detailed information about your disability, including its nature, when it began, and how it affects your ability to work.
Authorization for Release of Information: This form allows healthcare providers to share your medical records with Pearl Carroll. It ensures that all necessary medical information is accessible for evaluating your claim.
Medical Provider’s Statement: Completed by your healthcare provider, this document outlines your medical condition, treatment history, and any limitations that affect your ability to work. It’s essential for substantiating your claim.
List of Providers/Hospitals: You must provide a comprehensive list of all medical professionals and facilities that have treated you for your disability. This helps the claims team verify your treatment history.
Employee Accident Report: If your disability is work-related, you may need to submit this report, which documents the details of the incident that caused your injury or illness.
Discharge Papers: If you were treated in a hospital or urgent care center, including your discharge papers can provide critical information about your treatment and recovery.
Official Job Description: This document outlines your job duties and responsibilities. It helps establish the nature of your work and how your disability impacts your ability to perform those tasks.

Gathering these documents can streamline the claims process and improve the likelihood of a favorable outcome. Be sure to review each form carefully and provide accurate information to support your claim effectively.

Similar forms

The Pearl Carroll Disability Claim form shares similarities with the Social Security Disability Insurance (SSDI) application. Both documents require comprehensive personal information, including details about the claimant's medical condition and work history. Applicants must provide evidence of their disability, often necessitating medical records and documentation from healthcare providers. The SSDI application also emphasizes the need for accurate reporting of the claimant's work history and earnings, paralleling the Pearl Carroll form's focus on employment details and the nature of the disability.

Another document akin to the Pearl Carroll Disability Claim form is the Long-Term Disability (LTD) claim form. Like the Pearl Carroll form, the LTD claim form asks for detailed medical information, including a list of healthcare providers and treatment dates. Both forms require the claimant to describe how their disability affects their ability to work. Additionally, both documents often necessitate signatures from medical professionals to validate the information provided, ensuring that claims are supported by credible medical evidence.

The Workers' Compensation claim form is also comparable to the Pearl Carroll Disability Claim form. Each document collects information regarding the nature of the injury or illness, as well as the circumstances surrounding it. Claimants must specify the date of the incident and the extent of their disability, paralleling the Pearl Carroll form's request for similar details. Both forms aim to ensure that the claims process is transparent and that claimants receive the benefits they are entitled to based on their circumstances.

Similarly, the Family and Medical Leave Act (FMLA) certification form shares a focus on medical conditions affecting work. The FMLA form requires medical documentation to substantiate the need for leave, just as the Pearl Carroll form requires medical evidence to support a disability claim. Both documents prioritize the claimant's health and the necessity for time away from work, ensuring that employers are informed about the medical basis for the leave or disability claim.

The Health Insurance Claim Form (CMS-1500) also bears similarities to the Pearl Carroll Disability Claim form. Both documents require detailed information about the patient’s medical history and treatments received. The CMS-1500 form is specifically used for billing purposes, but it also requires the same type of provider information and treatment dates that the Pearl Carroll form requests. This overlap emphasizes the importance of accurate medical documentation in both insurance claims and disability claims.

Lastly, the Critical Illness Insurance claim form is similar to the Pearl Carroll Disability Claim form in that it demands a thorough account of the medical condition. Both forms require claimants to provide specific diagnoses, treatment details, and the impact of the illness on daily life. This focus on medical specifics is crucial for both types of claims, as it helps insurers assess the validity of the claim and determine the appropriate benefits to be awarded.

Dos and Don'ts

When filling out the Pearl Carroll Disability Claim form, it’s essential to follow specific guidelines to ensure a smooth process. Here’s a list of things you should and shouldn't do:

Do answer all questions completely on the Member Statement.
Do provide a detailed list of all providers and hospitals that treated you for your disability.
Do sign and date both the Member Statement and the Authorization for Release of Information.
Do ensure your Medical Provider completes both pages of their statement.

Don't leave any questions unanswered, as this may delay your claim.
Don't forget to notify Pearl Carroll & Associates if you recover or return to work.
Don't submit incomplete or inaccurate information, as this can result in denial of your claim.
Don't forget to keep a copy of the completed form for your records.

Misconceptions

Misconception 1: The Pearl Carroll Disability Claim form is too complicated to fill out.

While the form may seem lengthy, it is designed to gather all necessary information to process your claim efficiently. Taking your time to read through each section will help clarify what is needed.

Misconception 2: You don't need to provide a complete list of medical providers.

Providing a complete list of all medical providers who treated you is crucial. Missing information can delay your claim, so ensure you include every relevant provider.

Misconception 3: You can submit the form without your medical provider's input.

Your medical provider must complete their section of the form. Their insights into your condition are vital for the claims process, so don't skip this step.

Misconception 4: You don't need to notify Pearl Carroll if you recover or return to work.

It's essential to inform Pearl Carroll immediately if you recover or return to work. This ensures that you comply with the terms of your benefits and avoid potential issues down the line.

Misconception 5: Faxing your claim form guarantees it will be processed faster.

While faxing is an option, remember that it may take 24 to 48 hours for confirmation of receipt. Ensure you keep a copy for your records, regardless of the submission method.

Misconception 6: The form can be submitted without a signature.

A signature is required on both the Member Statement and the Authorization for Release of Information. Submitting unsigned forms can lead to delays or rejections.

Misconception 7: You don’t need to keep a copy of the completed form.

Always keep a copy of your completed form for your records. This can be helpful if any questions arise about your claim later on.

Key takeaways

When filling out the Pearl Carroll Disability Claim form, there are several important steps to keep in mind. Here are key takeaways to ensure a smooth process:

Complete the Member Statement: Answer all questions thoroughly to avoid delays in processing your claim.
List of Providers: Provide a complete list of all healthcare providers and hospitals that treated you for your disability.
Signatures Required: Ensure that you date and sign both the Member Statement and the Authorization for Release of Information.
Medical Provider’s Statement: Have your medical provider complete both pages of their statement to support your claim.
Return Address: Send the completed form to Pearl Carroll & Associates LLC, Disability Claims Unit, at the specified address.
Notify of Recovery: If you recover or return to work, inform Pearl Carroll immediately by submitting the required statement.
Contact Information: For questions, call the Office of the Administrator at 1-800-697-2732. Fax submissions may take 24-48 hours for confirmation.
Documentation: Attach necessary documents, such as the Employee Accident Report if the disability is work-related or discharge papers from a hospital visit.
Accurate Information: Ensure that all information provided is complete and accurate to avoid any potential issues with your claim.

By following these guidelines, you can help facilitate a smoother claims process with Pearl Carroll & Associates.