Mailing Address: 711 High St. Des Moines, IA

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Gwen Miles
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1 Mailing Address: 711 High St. Des Moines, IA Principal Life Insurance Company Psychiatric Questionnaire Patient Name Date of Birth MM/DD/YYYY Policy Number(s) To The Provider Please complete the following questionnaire and submit a copy of your records. Date of initial visit: 1. What was the patient s chief complaint/symptoms at the initial visit with you? When did these symptoms first appear? 2. Please check symptoms present at the most recent visit of Anxiety Fearfulness Gloomy thought Suicidal ideation Social withdrawal Tearfulness MM/DD/YYYY Somatic pre-occupation Anger Flat affect Mood swings Change in daily activities Other symptoms not listed: Dates of all visits: Dates of any hospitalizations & name of hospital: 3. What stressful events occurred in the patient s life about the same time as the onset of the symptoms, whether or not they seem to be causally related. a. b. c. 4. What role do you feel that alcohol and/or other drugs have played in this problem? None Minimal Moderate Substantial KK This completed document is for restricted use only. No part may be copied nor disclosed without prior consent of The Principal. Page 1 of 6

2 5. Please give us the results of any recent abnormal lab studies or serum drug levels which you have obtained. Date MM/DD/YYYY Test Results 6. Please list patient s current medications, response and compliance. Drug Response Compliance 7. What other treatment is the patient receiving? Type of Treatment Frequency By Whom? Professional Degree of Provider 8. Is the frequency of treatment consistent with recommendations of physician and/or therapist? Yes No 9. Please describe the findings on the patient s mental status examination at his or her most recent visit. a. Appearance b. Manner of Speech c. Perceptual Abnormalities d. Mood e. Affect f. Thought content g. Intelligence h. Insight i. Motivation for Change KK This completed document is for restricted use only. No part may be copied nor disclosed without prior consent of The Principal. Page 2 of 6

3 10. Axis I (Mental disorder): Axis II (Personality Disorder): Axis III (Medical Disorder): Axis IV (Severity of Stressors): None Mild Moderate Severe Extreme Catastrophic Axis I (global assessment of functioning): (Check one) Good function of all areas (90) Slight impairment (80) Minor impairment (70) Moderate impairment (60) Serious impairment (50) Major impairment in several areas (40) Impairment in nearly all areas or Thought disorder (30) Suicidal gestures or grossly impaired functions (20) Minimal self care or suicidal with intent (10) 11. Are there any unusual circumstances that are contributing to the patient s condition or delaying his/her recovery? Yes No If yes, please explain. 12. Being as specific and objective as possible, please list all of the patient s functional limitations in each area. Physical: Work: Family: Social: KK This completed document is for restricted use only. No part may be copied nor disclosed without prior consent of The Principal. Page 3 of 6

4 13. On what date did you advise the patient to restrict his/her work activities? If you did not restrict the patient s work activities, do you feel the patient is currently capable of performing his/her regular occupation or any other occupation? Yes No 14. Please explain the specific restrictions and limitations. 15. When will the patient be able to return to work: Part-Time? Full-Time? 16. Please describe treatment plan to return the patient to functional status? a. b. c. d. 17. Do you believe the patient is competent to endorse checks and direct the use of the proceeds thereof? Yes Fraud Statement No ALL OTHER STATES Any person who knowingly and with intent to defraud any insurance company or other person, submits a statement of claim or any application form containing any material false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act which is a crime. Such actions may be considered felonies and subject to criminal and civil penalties, including imprisonment and fines. (See pages 5 and 6 for your specific state language.) Physician Information Physician s Name (Please print) Degree Specialty Telephone Number Street Address City State ZIP Physician s Signature Date MM/DD/YYYY KK This completed document is for restricted use only. No part may be copied nor disclosed without prior consent of The Principal. Page 4 of 6

5 Fraud Statements Alabama Arizona California Colorado DC Residents Washington Florida Indiana Kentucky Louisiana Maryland Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. For your protection Arizona Law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. For your protection California Law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the subject. Any person who knowingly and with intent to injure, defraud, or deceive any insurance company files a statement of claim containing any false or misleading information is guilty of a felony of the third degree. Any person who knowingly and with intent to injure, defraud, or deceive any insurance company files a statement of claim containing any false or misleading information is guilty of a felony of the third degree. Any person who knowingly and with intent to defraud any insurance company or files a statement of claim containing any materially false or misleading information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. KK This completed document is for restricted use only. No part may be copied nor disclosed without prior consent of The Principal. Page 5 of 6

6 Minnesota New Jersey New Mexico New York Ohio Oklahoma Oregon Pennsylvania Tennessee Virginia A person who files a claim with intent to defraud or helps commit fraud against an insurer is guilty of a crime. Any person who knowingly files a statement of a claim containing any false or misleading information is subject to criminal and civil penalties. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. 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 stated value of the claim for each such violation. Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing false or deceptive statement is guilty of insurance fraud. WARNING: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud. 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 subjects such person to criminal and civil penalties. It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Any person who, with the intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law. KK This completed document is for restricted use only. No part may be copied nor disclosed without prior consent of The Principal. Page 6 of 6

Critical Illness Insurance Insured s Statement (Please print Attach separate sheet if additional space required) Insured s Name Claim#:

Critical Illness Insurance Insured s Statement (Please print Attach separate sheet if additional space required) INSURED INFORMATION Insured s Name Claim#: Soc. Sec. No. - - Date of Birth / / (MM/DD/YY)