WebForms. Fill out and submit Part B – Physician/Practitioner’s Certificate. Fill out and submit Part D – Physician/Practitioner’s Certification. If you are an accredited religious … Web• Insured/Patient Authorization (last page): Please sign and date this form, provide a copy to your attending physician, and fax the completed form to 1-800-447-2498. If you prefer, it …
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WebWe offer a variety of downloadable forms to make it easy to do business with us. Search our forms library or access our electronic signature and IRS forms today. Log In. ... Unum is a … Webform to 1-800-447-2498 or mail it to the address noted above. If you are applying for the Be Well Benefit, this statement is not required. Unum is not responsible for expenses associated with the completion of this form. • Insured/Patient Authorization (last page): Please sign and date this form, provide a copy to your attending physician ... WebPART B - ATTENDING PHYSICIAN’S STATEMENT . Notes: (1) The fee for this report is to be paid by the policyowner. (2) Please return the completed Attending Physician’s Statement … healy subluxe vinyl