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Free Pearl Carroll Disability Claim PDF Template

The Pearl Carroll Disability Claim form is a comprehensive document designed to facilitate the process for individuals filing a disability income claim. This form requires detailed information about the claimant's disability, treatment providers, and a clear statement of recovery or return to work, ensuring that all necessary data is provided to Pearl Carroll & Associates LLC for processing. It is imperative for claimants to accurately fill out the member statement, medical provider's statement, and the authorization for release of information to avoid any delays in their claim.

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Free Pearl Carroll Disability Claim PDF Template

Outline

When dealing with a disability claim, the comprehensive process outlined by Pearl Carroll & Associates LLC becomes crucial for members aiming to navigate through their disability income claim effectively. The detailed instructions emphasize the necessity of filling out the Member Statement accurately, providing a thorough List of Providers/Hospitals involved in the treatment of the disability, and ensuring both the Member's Statement and the Authorization for Release of Information are duly signed and dated. The claim form further instructs medical providers to complete their portion with precision, signifying the collaborative effort required from both the claimant and medical personnel to process a claim successfully. Along with the procedural steps, the form outlines clear pathways for communication, including addresses and contact information, facilitating a streamlined submission and follow-up process. Additionally, it underscores the importance of notifying Pearl Carroll & Associates immediately upon any change in the claimant's work status, adhering to ethical and legal guidelines. The inclusion of specific instructions for diverse claim types—spanning from member disability to survivor benefits—illustrates the form's encompassing nature, designed to cater to a wide range of circumstances faced by union members. This careful delineation of steps, combined with the legal implications of fraudulent claims highlighted in the document, encapsulates the dual focus on thoroughness and integrity within the disability claim process.

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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:	____________________________________					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 Customercare@PearlCarroll.com
	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 Customercare@PearlCarroll.com

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 CustomerCare@PearlCarroll.com

CSEA DI ed 10/2016

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Document Attributes

Fact Name	Fact Details
Form Submission Address	Pearl Carroll & Associates LLC, Disability Claims Unit, 12 Cornell Road, Latham, NY 12110
Contact Information	Email: Customercare@PearlCarroll.com, Phone: 1-800-697-2732, Fax: 518-640-8105
Notification Requirement	Individuals must notify Pearl Carroll & Associates immediately upon recovery or return to work.
Authorization Validity Period	The authorization for the release of information is valid for 24 months from the date signed.

How to Fill Out Pearl Carroll Disability Claim

After experiencing a health setback that affects your ability to work, it's important to take the correct steps towards filing a disability claim. This not only ensures that you receive the necessary support during your recovery but also that your benefits align with your needs. The Pearl Carroll Disability Claim Form is designed to streamline the application process for receiving disability income benefits. Here's a guide on how to fill out this form correctly to ensure your submission is complete and accurate.

Start by detaching the instructions notice for your future reference.
Fill out the Member Statement section with accurate details about your disability, including the full list of providers and hospitals that treated you for this disability.
Ensure both the Date and your Signature are provided on the Member Statement and the Authorization for Release of Information.
Have your Medical Provider complete the required information on both pages dedicated to the Medical Provider’s Statement.
Complete the section indicating your recovery or return to work status, ensuring to provide the specific dates and nature of your return to work or recovery.
For the Member’s Disability Income Form, provide all necessary personal information including your name, date of birth, social security number, and contact details.
Detail your occupation, the nature of your disability, whether the disability is work-related or due to an injury, and any attempts to return to work. Include the specific dates relevant to your treatment and work status.
List all providers, hospitals, and pharmacies that have been involved in your treatment. Attach additional sheets if necessary, ensuring clarity and completeness.
Answer questions related to other sources of income you might be receiving or eligible to receive, such as Workman’s Compensation or Social Security Disability, among others.
Sign and date the bottom of the form, affirming the truthfulness of your answers and agreeing to notify New York Life Insurance Company of any return to work.
Review the details for any errors or omissions, then mail or email the completed form along with the Authorization for Release of Information to the addresses provided.

Once your form is submitted, expect a processing period. During this time, your claim will be assessed based on the information you've provided. It is crucial to keep a copy of your submission for your records. For any questions or concerns about your claim or the filling process, reach out to Pearl Carroll & Associates via phone or email as indicated in the form instructions. Remember, staying informed and proactive about your claim is essential for a smooth and timely resolution.

More About Pearl Carroll Disability Claim

How do I complete the Pearl Carroll Disability Claim form?

Start by accurately filling out the Member Statement section, and ensure you provide a complete list of all healthcare providers and hospitals involved in your treatment. It's also necessary to date and sign the Members Statement and the Authorization for Release of Information. Have your Medical Provider fill out the Medical Provider’s Statement. Once completed, submit the form to Pearl Carroll & Associates LLC, either by mail or email.
Where should I send my completed Disability Claim form?

Send the completed form to Pearl Carroll & Associates LLC, Disability Claims Unit, 12 Cornell Road, Latham, NY 12110. Alternatively, you can email it to Customercare@PearlCarroll.com.
What should I do if I recover or return to work?

If you recover or return to work, notify Pearl Carroll & Associates immediately. You can complete the Statement of Recovery or Return to Work section of the form and mail it to the address provided or email it.
Who can I contact if I have questions about my Disability Income benefits?

If you have questions, call the Office of the Administrator at 1-800-697-2732. For fax inquiries, use the number 518-640-8105. Please note that fax receipt confirmations may take 24 - 48 hours.
What information is needed from my Medical Provider?

Your Medical Provider must complete both pages of the Medical Provider’s Statement, which includes information about your diagnosis, treatment, and prognosis. This is critical for the evaluation of your claim.
Do I need to list all the providers who have treated me?

Yes, provide a complete list of all providers and hospitals that have treated you for your disability. Failure to include all providers may delay the processing of your claim.
Is there anything specific I need to do if my disability is work-related?

If your disability is work-related, you must attach a copy of the Employee Accident Report signed by your manager to your claim form.
What if my disability is due to a Motor Vehicle Accident?

If your disability stems from a Motor Vehicle Accident, you need to attach the MV-104A Police Report to your claim form.
Can I email my Disability Claim form and supporting documents?

Yes, you can email the completed Disability Claim form along with all supporting documents to Customercare@PearlCarroll.com.
What happens if I need to revoke my Authorization for Release of Information?

You can revoke your authorization at any time by notifying New York Life in writing at the address provided on the form. However, your revocation will not affect any use of the information that occurred before you revoked your authorization.

Common mistakes

Not answering all the questions on the Member Statement of the Disability Income claim form is a common error. Each question is aimed at understanding the situation better and missing responses can lead to delays.

Failing to compile a complete List of Providers/Hospitals that administered treatment for the disability causes unnecessary gaps in information, which could impact the outcome of the claim.

Overlooking the need to date and sign both the Member’s Statement and the Authorization for Release of Information jeopardizes the verification process, delaying or even potentially invalidating the claim.

It's often overlooked to ensure that the Medical Provider completes both pages of their statement. This detailed documentation is crucial for a thorough evaluation of the claim.

Some claimants mistakenly send the forms to the wrong address or forget to notify Pearl Carroll & Associates LLC immediately upon recovery or return to work, which can lead to overpayments that have to be repaid.

Not providing a detailed description of the nature of the disability and if it's work-related or due to an injury can lead to misunderstandings about the claim's validity or its scope.

One critical mistake is neglecting to attach required documentation, such as the Employee Accident Report if the disability is work-related, or the MV-104A Police Report if it’s due to a Motor Vehicle Accident.

Forgetting to sign the form not only on the main page but also on the Authorization for Release of Information Form overlooks a basic yet essential step in validating the request for benefits.

Lastly, failing to acknowledge the fraud warning statement for New York Residents by not providing complete and true answers, or attempting to conceal information, risks severe penalties beyond the denial of the claim.

In summary, correctly filling out the Pearl Carroll Disability Claim form requires attention to detail, understanding the documentation requirements, and a commitment to accuracy. Avoiding these mistakes not only streamlines the process but also ensures that the claim is evaluated fairly and promptly.

Documents used along the form

When filing a disability claim using the Pearl Carroll Disability Claim form, it's not just about filling out the form itself. The process often requires the inclusion of various other forms and documents to ensure that the claim is comprehensively reviewed and processed efficiently. These documents play a crucial role in providing a full picture of the claimant's condition, the nature of their disability, their medical history, and any financial benefits they might be entitled to. Below is a list of documents that are commonly used in conjunction with the Pearl Carroll Disability Claim form.

Physician's Statement: This detailed statement from the claimant's doctor describes the nature of the disability, the prognosis, and the expected duration of the disability. It often includes specific limitations and capabilities of the claimant.
Authorization for Release of Medical Information: This document gives the insurance company permission to access the claimant's medical records. It's critical for verifying the information provided in the disability claim.
Employee Accident Report: If the disability is related to a workplace incident, this report provides an official account of the circumstances leading to the injury or condition, often required for work-related disability claims.
Copy of the Official Job Description: Understanding the duties and physical demands of the claimant's job can help assess how the disability affects their ability to work. This document is used to compare the claimant's capabilities pre- and post-disability.
W-2 Forms or Pay Stubs: These documents are used to verify the claimant's income, which is essential for determining the appropriate benefit amount.
Copy of Police Report (for Motor Vehicle Accidents): If the disability stems from a motor vehicle accident, a police report provides an impartial third-party account of the incident, which can be crucial for validating the claim.
Discharge Papers from Hospital or Urgent Care Center: These papers contain information on treatments received, the claimant's condition upon discharge, and any follow-up care instructions, offering insight into the severity and immediate impact of the condition.
Psychological Evaluations: For disabilities with a psychological component, this evaluation can document the mental and emotional state of the claimant, providing another layer of understanding to the claimant's condition.

In conclusion, while the Pearl Carroll Disability Claim form is a vital component of the claim process, it's the supplementary documents that often provide the depth of information needed for a thorough assessment. Each document adds a layer of detail, helping insurance companies make informed decisions regarding the claimant's eligibility and the extent of benefits required. Keeping these additional forms in mind and ensuring their accurate completion can significantly impact the outcome of a disability claim.

Similar forms

Short-Term Disability Insurance Claim Forms: Much like the Pearl Carroll Disability Claim form, short-term disability forms require detailed information about the nature of the claimant's disability, whether the disability is work-related, and when the claimant expects to return to work. Both types of forms often request a list of medical providers and a detailed account of medical treatments received.
Long-Term Disability Insurance Claim Forms: Similar to long-term disability claim forms, the Pearl Carroll form collects comprehensive personal, employment, and medical information to assess eligibility for disability benefits. This process includes documentation from medical professionals and a detailed description of the disability's impact on the claimant's ability to work.
Workers' Compensation Claim Forms: These forms and the Pearl Carroll document share a common purpose in collecting information on whether a disability is work-related. Both require details about the incident leading to the disability, treating physicians, and expected duration of work incapacity.
Social Security Disability Benefits Application: Like the Pearl Carroll form, applications for SSDI benefits require extensive documentation of the disability, treatment providers, and how the disability affects the claimant’s work abilities. Both necessitate official medical evidence and statements regarding the disability’s impact on daily living and work.
Life Insurance Claim Forms: While serving different purposes, life insurance claim forms and the Pearl Carroll Disability Claim form both require thorough personal information and documentation. For life insurance, it's to prove a death occurred; for disability insurance, it's to prove a disability exists and affects work ability.
Medical Leave Request Forms under FMLA: These forms, similar to the Pearl Carroll form, require medical certification to substantiate the need for leave due to serious health conditions that make the employee unable to perform their job, including expected return to work and the necessity for intermittent leave or a reduced work schedule.
Health Insurance Claim Forms: Both types of forms necessitate detailed health and treatment information, provider details, and the specific services rendered, aiming to validate claims for financial coverage, albeit for different reasons.
Personal Injury Claim Forms: Personal injury claims and Pearl Carroll's disability claims share the necessity for detailed incident reports, a comprehensive account of resulting injuries, medical treatments, and their impact on the claimant’s capacity to work or perform daily activities.
Auto Insurance Medical Claim Forms: Similarities include the requirement for detailed information on injuries sustained during an incident, healthcare providers, treatment dates, and how injuries impact the claimant's daily life and work abilities, although the focus for auto insurance claims is on injuries related to vehicle accidents.

Dos and Don'ts

When filling out the Pearl Carroll Disability Claim form, it's crucial to navigate the process with care to ensure your claim is processed efficiently and accurately. Here are key dos and don'ts to keep in mind:

5 Things You Should Do

Fully complete the Member Statement: Make sure to answer all questions in the Member Statement section of your Disability Income claim form. Incomplete answers can delay the processing of your claim.
Provide a complete list of providers: Ensure you list all providers and hospitals that have treated you for your disability. Missing information may hinder your claim's review.
Sign the necessary sections: Don't forget to date and sign the Member's Statement and the Authorization for Release of Information sections. Unsigned forms are considered incomplete.
Get your Medical Provider involved: Have your Medical Provider complete both pages of the Medical Provider’s Statement. Their input is crucial for substantiating your claim.
Notify if you return to work: If you recover or return to work, promptly notify Pearl Carroll & Associates by completing the relevant section of the form. Timely communication is vital.

5 Things You Shouldn’t Do

Leave sections blank: Avoid skipping questions. If a question doesn’t apply, it’s better to note it as "N/A" (not applicable) rather than leaving it blank.
Submit without reviewing: Don’t rush to submit your form without double-checking your entries for accuracy and completeness. Errors can delay processing.
Omit provider information: Do not forget to include comprehensive details about your providers, including those not directly related to your current claim but who have relevant medical history.
Forget about attachments: If your disability is due to a work-related injury or a motor vehicle accident, failing to attach the required documents like the MV-104A Police Report or Employee Accident Report can stall your claim.
Overlook the privacy notice: New York residents especially should not ignore the fraud warning statement and the implications of submitting false information.

Misconceptions

Understanding the process and requirements for submitting a Pearl Carroll Disability Claim form can seem daunting. To help clarify, here are five common misconceptions about the form and the facts that address them:

Misconception 1: You must wait until your recovery is complete to notify Pearl Carroll & Associates. In reality, it is crucial to inform Pearl Carroll & Associates immediately upon your recovery or return to work, whether it's full-time, part-time, light duty, or another job. Quick communication ensures that your claim is updated promptly, which helps in managing your benefits accurately.
Misconception 2: Email is not an acceptable method to submit the recovery or return to work statement. Contrary to this belief, Pearl Carroll & Associates does accept notifications of recovery or return to work through email at Customercare@PearlCarroll.com. This digital option provides a convenient and timely way to convey important updates about your employment status.
Misconception 3: The form requires only the details of your most recent medical provider. The form actually requests a comprehensive list of all providers and hospitals that have treated you for your disability. Providing complete information is essential to avoid delays in your claim, as missing details can hinder the evaluation process.
Misconception 4: The Disability Income Claim form is the only document required for your claim. The submission process requires both the Member Statement and the Medical Provider’s Statement, along with an Authorization for Release of Information. Together, these documents offer a full view of your situation, facilitating a thorough assessment of your claim.
Misconception 5: All communication must be done through mail or fax. Although mailing or faxing documents is a viable option, Pearl Carroll & Associates also provides a phone number (1-800-697-2732) for inquiries. This additional line of communication allows you to ask questions or clarify doubts about your Disability Income benefits request.

Dispelling these misconceptions enables a smoother, more informed process when filing a disability claim with Pearl Carroll & Associates. Always ensure to review the instructions and requirements carefully, and when in doubt, reach out directly to their office for assistance.

Key takeaways

When submitting a Disability Claim Form to Pearl Carroll & Associates, it is vital to remember these key points to ensure a smooth processing of your claim:

Complete the Member Statement thoroughly, ensuring all questions are answered to provide a clear view of your claim.
A List of Providers/Hospitals is required. This should include every provider that treated you for the disability in question. Leaving out information can delay your claim.
It is necessary to date and sign both the Member’s Statement and the Authorization for Release of Information, as this verifies the truthfulness and consent to process the information provided.
Your Medical Provider must fill out both pages of the Medical Provider’s Statement. Their input is crucial for assessing your claim.
Send the completed form to Pearl Carroll & Associates LLC, Disability Claims Unit, located at 12 Cornell Road, Latham, NY 12110, for processing.
If you recover or return to work, it is imperative to notify Pearl Carroll & Associates immediately by filling out and sending the designated statement. It helps adjust your benefits accordingly.
Should you have any questions or need clarification on your Disability Income benefits request, contacting the Office of the Administrator at 1-800-697-2732 is advised.
Confidentiality: Be aware that once information is released, it might be used in ways beyond the initial intent, such as being required by regulatory or government agencies.

By following these guidelines, you help ensure that your Disability Claim is processed efficiently and accurately, providing the support you need during your period of disability.

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Form Wh-58 - It allows for transparency in the settlement process, giving employees clear details about the compensation they are receiving.

Va Form 10-10ez - Applicants are reminded through the VA 10-10D form about the necessity of reporting any changes in marital status, impacting CHAMPVA coverage.