202 by shitingting

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									Sun Life Assurance Company of Canada
227 King St S, PO Box 1601 Stn Waterloo, Waterloo ON N2J 4C5
Critical Illness - Physician’s Statement (Coronary Artery Bypass Surgery)
The patient is responsible for obtaining this form and paying any charges relating to its completion.


Patient’s Name: _____________________________________________________                      Date of Birth
                                                                                                              Day   Month   Year


I hereby authorize the release of any information in respect of this claim under policy number(s) _________________________ to my
insurer, Sun Life Assurance Company of Canada.


Date                                 Signature of Patient: _____________________________________________________
             Day   Month   Year



1. a) Has your patient had heart surgery to correct narrowing or blockage of one or more coronary arteries with bypass grafts?
      ❑ Yes ❑ No

   b) Was the surgery recommended by a consultant cardiologist registered in Canada?               ❑ Yes ❑ No

       If “Yes”, please provide the name and address of consultant cardiologist registered in Canada who recommended the surgery.

       ____________________________________________________________________________________________________


   c) When did the surgery take place?
                                              Day     Month     Year

   d) Where did the surgery take place? __________________________________________________________________________

   e) Detail the exact surgical procedure (include number and site(s) of grafts.) Attach copy of operative report.

   ________________________________________________________________________________________________________

   f) Provide the name and address of hospital and name of surgeon who undertook the procedure.               __________________________

   _________________________________________________________________________________________________________


2. a) When did your patient’s symptoms first appear?
                                                                                     Day   Month       Year



   b) When did your patient first consult a physician for his/her condition?
                                                                                     Day   Month       Year



   c) When did your patient first consult you for his/her condition?
                                                                                     Day   Month       Year



   d) When did your patient first become aware of his/her condition?
                                                                                     Day   Month       Year


3. Has your patient had any prior history of heart problems or had any previous episodes of the underlying condition?              ❑ Yes ❑ No

   If “Yes”, please describe

   ________________________________________________________________________________________________________

4. Are you aware of any members of your patient’s immediate family who have suffered from a heart condition or a similar condition
   or undergone heart surgery? ❑ Yes ❑ No

   If “Yes”, please provide details ____________________________________________________________________________

   _____________________________________________________________________________________________________

5. Has your patient consulted any other physician(s) or attended any hospital for this or any other related illness? ❑ Yes ❑ No

   If “Yes”, please provide names and addresses _______________________________________________________________

   _____________________________________________________________________________________________________

                                    Products are issued by Sun Life Assurance Company of Canada
E202-02-06                                          Please send original after faxing a copy.                                           Page 1 (2)
6. Primary diagnosis ______________________________________________________________________________________

   Secondary diagnosis ____________________________________________________________________________________

   Contributing factors _____________________________________________________________________________________


7. Describe in detail your patient’s condition leading to surgery _____________________________________________________

    ______________________________________________________________________________________________________

8. What investigations, test or procedures were performed prior to surgery? Please provide details __________________________

   ________________________________________________________________________________________________________


9. Does your patient smoke?     ❑ Yes ❑ No

   If “No”, has your patient ever smoked?    ❑ Yes ❑ No

   If “Yes”, please provide details of smoking history _________________________________________________________________

   _________________________________________________________________________________________________________


10. Give details of any conditions you or any other physicians have treated your patient for whether or not related to current illness.

   _________________________________________________________________________________________________________

   _________________________________________________________________________________________________________

   _________________________________________________________________________________________________________



Would you please provide us with copies of any specialist or hospital reports, including copies of any pathology reports,
together with any tests, readings, or similar evidence in support of your patient’s claim.




Name         ______________________________________

Specialty    ______________________________________

Address      ______________________________________

             ______________________________________

             ______________________________________

             ______________________________________


               )
Telephone (______________________________________


Date         ______________________________________                  Signature ____________________________________________




E202-02-06                                      Please send original after faxing a copy.                                          Page 2 (2)

								
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