EPIC TDI-45 Part C

  • Aloha,

    For your convenience, we can complete the physician’s section of the TDI-45 form for you. Please provide the required medical information to help expedite the processing of your patient’s disability claim.

    Mahalo,

    The EPIC Claims Team

  • PART C - PHYSICIAN'S STATEMENT

  • Date of Birth:*
     - -
  • Gender*
  • If pregnancy, expected delivery date:
     - -
  • Was patient's disability caused by their employment?*
  • Was Physician's Report WC-2 filed?
  • Format: (000) 000-0000.
  • Was patient hospitalized?*
  • From:
     - -
  • To:
     - -
  • Is surgery indicated?*
  • Are you referring patient to another physician?*
  • Was patient referred to you?*

  • Please complete the following:  

  • Date of your first treatment of this disability:*
     - -
  • First date patient was unable to perform the duties of employment:*
     - -
  • Date of your most recent treatment of this disability:*
     - -
  • Date patient will be able to return to work (estimate):*
     - -
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  • Physician / Clinic Information:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • I hereby certify that the above information is true and complete to the best of my knowledge.

  • Clear
  • Date*
     / /
  • Should be Empty: