Critical Illness

							                                                               Critical Illness
                                                               Attending Physician’s Statement – Insulin-dependent diabetes
Mail this completed form to:
Living Benefits Claims                                         • Use this form to provide details of the condition or disease for the person identified in
Manulife Financial                                               section 1.
2 Queen Street East, 5th Floor                                 • Answer all questions. Incomplete forms may delay the processing of the claim.
PO BOX 4606 STN A                                              • We, us, and our refer to The Manufacturers Life Insurance Company. In section 1, you
TORONTO ON M5W 4Z2                                               and your refer to the insured person. In section 2, you and your refer to the physician.
Print clearly.                                                 • If you have any questions, call us at 1-866-575-0684.
                                    Policy number                      Name of insured person (first, middle initial, last)                            Date of birth (dd/mmm/yyyy)
1 a) Personal information
      Complete, sign and date
      section 1 before your         Address (street and number)                       Apt.     City or town                       Province             Postal code
      physician completes
      section 2.

1 b) Authorization to                By signing below:
     release personal                • you authorize and direct the doctor preparing this Attending Physician’s Statement to release information, records or
                                       knowledge about you and your health to The Manufacturers Life Insurance Company. The information will be used to
     information                       administer a claim being made for the policy identified in section 1 a).
                                     • you agree that this authorization will be in effect for one year from the date you sign it.
                                     • you acknowledge that you are responsible for providing this form to your doctor to complete, and that you will
                                       have to pay any costs your doctor may charge for completing this form.
                                     • you understand that incoming and outgoing calls between Manulife Financial and our clients are recorded so that we
                                       can later verify the information exchanged.
                                     • you understand that your personal information will be used and stored as described in Manulife Financial’s policy and
                                       procedures document. (This document is available from the Privacy Office, Individual Insurance, 25 Water St. S.,
                                       P.O. Box 800, Station C, Kitchener, ON N2G 4Y5 or on the website at www.manulife.ca>Privacy Policy.)
                                    Signature of insured person or insured person’s legal representative if insured person is a minor or incompetent   Date (dd/mmm/yyyy)
                                    (attach applicable documents)
                                    ✘
2 a) Medical information             1. a) When did your patient first have symptoms?                                   Date (dd/mmm/yyyy)

      All of section 2 must be
      completed, signed and                   What were they?
      dated by the physician.
      Answer all questions
      completely or indicate n/a.



                                           b) When did your patient first consult you for this condition?               Date (dd/mmm/yyyy)




                                           c) How long has this person been your patient?

                                                                                                                                         years                months

                                     2. a) How was the diagnosis made?



                                           b) When was the diagnosis discussed with your patient?                       Date (dd/mmm/yyyy)




                                     3. a) When was your patient determined to be insulin dependent?                    Date (dd/mmm/yyyy)


                                           b) How was this determination made?




                                           c) Has your patient required insulin for a continuous period of 12 months?                                                  No       Yes
                                              If yes, provide details.




The Manufacturers Life Insurance Company                                         Page 1 of 2                                                                    NN1490E (09/2008)
2 a) Medical information              4.        Were there any additional consultations sought for this condition?                                               No    Yes
     (continued)                                If yes, provide copies of reports.

                                      5.        Is there a family history of diabetes?                                                                           No    Yes
                                                If yes, provide details.




                                      6.        Is there any other significant family history?                                                                   No    Yes
                                                If yes, provide details.




                                      7.        Does your patient use any form of tobacco, marijuana, nicotine products or nicotine substitutes?                 No    Yes

                                                If yes, tell us the amount per day.                              Amount per day




                                                How long has your patient used these?

                                                                                                                                  years                 months

                                                If no, did your patient previously use any of these?                No            Yes

                                                When did your patient quit?                                      Date (dd/mmm/yyyy)




                                      8.        Tell us any other information that might support this claim.




                                      9.        The test results associated with your diagnosis are critical in determining your patient’s eligibility for coverage under
                                                this policy. Please include test results with this APS.


2 b) Physician’s signature            By signing below you confirm that to the best of your knowledge, the information on this APS about your patient is current,
                                      correct and complete.
      Note: Your patient is           Name of physician (first, middle initial, last)                                                     Telephone number
      responsible for paying any
      fee charged for completion                                                                                                          (         )
      of this Attending Physician’s
                                      Address (street and number)                                 City or town             Province              Postal code
      Statement (APS).


                                      Certified specialist

                                           No           Yes, specify

                                      Signature of physician                                                                              Date (dd/mmm/yyyy)

                                      ✘




The Manufacturers Life Insurance Company                                            Page 2 of 2                                                            NN1490E (09/2008)