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Attending Doctor's Statement - Income Protection
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Attending Doctor's Statement - Income Protection
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Attending Doctor's Statement - Income Protection
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Attending Doctor's Statement - Income Protection
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This form is to be completed by the attending medical doctor and relates to a claim for Income Protection.

Important note
If there is a charge for completing this form, the payment is the responsibility of the patient. TAL Life Limited will not be responsible for any costs associated with the completion of this form.

Patient's details

Attending Doctor's Statement - Income Protection
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Patient's name

Medical - Diagnosis

Attending Doctor's Statement - Income Protection
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Diagnosis

Since submitting your last report, on what date(s) has your patient consulted you?

Date

Please list all active medical condition(s) impacting your patient's work capacity

Condition

Please list any other active medical condition(s)

Condition

Are there any complicating factors affecting or prolonging your patient's recovery?

Medical - Treatment

Attending Doctor's Statement - Income Protection
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Treatment

Please list any new practitioners involved in your patient’s management.

Practitioner

Medical - Capacity for work

Attending Doctor's Statement - Income Protection
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Capacity for work

Since becoming unfit for work, has your patient been able to perform suitable duties?
If your patient has not returned to work, please specify when you expect this to occur and from what date. Please provide approximate date if exact date is unknown.
Have you considered or are you considering a return to work plan or rehabilitation for your patient?

Additional information

Attending Doctor's Statement - Income Protection
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Other

Have medical certificates been provided in respect of your patient's condition to any other organisation, insurer or government body (eg Centrelink, DVA, workers compensation insurer)?

Organisation

Additional information

Test results

Attending Doctor's Statement - Income Protection
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Test results

Please attach copies of the relevant:
Test results
File:
Clinical notes
File:

Lodge statement

Attending Doctor's Statement - Income Protection
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Privacy statement

TAL Life Limited is bound by obligations imposed by current privacy legislation. Information received or requested from you is handled in accordance with these obligations. TAL Life Limited requires that all entities adhere to relevant privacy obligations when dealing with personal and sensitive information about our customers.

Medical attendant

Specialist

Attendant's contact details

Signature

I certify that I have examined the patient and that all statements made in this form are correct.
Please provide a signature
Signature
Call
Reference Code
Been here before?
Change of mind?
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Insurance is provided by TAL Life Limited ABN 70 050 109 450 AFSL 237848 to VIS Nominees Pty Ltd ABN 11 006 586 367 AFSL 235097 as trustee of The Victorian Independent Schools Superannuation Fund ABN 37 024 873 660