The Lincoln National Life Insurance Company

Disability and Life Claims

PO Box 2578
Omaha, NE 68103-2578
Phone No.: (866) 317-9383
Secure Fax No.: (603) 334-0401

September 20, 2024

Richard K. Albrecht
234 SAMUEL BLVD P4
UNIT P4
COPPELL, TX 75109

RE: Short Term Disability (STD) Benefits

HD Supply, Inc.
Claim #: 16193389

Dear Richard:

Please complete attached form and send back via email or fax:

email: [email protected]
fax: 603-334-0401

If you have any questions regarding this matter, please contact your assigned Disability Case
Manager at the number below.

Sincerely,

Nora R.
Claims Examiner Ii, Std 1
Phone No.: (866) 317-9383 Ext. 89169
Secure Fax No.: (603) 334-0401

Attachments: Authorization - Medical

Attending Physician's Statement

1 of 1
 The Lincoln National Life Insurance Company
Disability and Life Claims
PO Box 2578
Omaha, NE 68103-2578
Phone No.: (866) 317-9383
Secure Fax No.: (603) 334-0401

AUTHORIZATION FOR THE RELEASE OF INFORMATION INCLUDING PROTECTED

HEALTH INFORMATION

I HEREBY AUTHORIZE THE DISCLOSURE OF INFORMATION ABOUT ME AS DESCRIBED BELOW:

Person(s) or group(s) of persons authorized to disclose the information: Any physicians, medical practitioners, hospitals,
clinics, HMOs, long-term care facilities, medical or medically-related facilities, pharmacies, insurance companies, credit or consumer
reporting agency, financial/educational institutions, current or former employer, governmental agency, MIB Inc., policy holder,
reinsurance companies, policy or benefit plan administrator, and any insurance support organizations.
Person(s) or group(s) of persons authorized to collect or otherwise receive the information: The particular Company in the
Lincoln Financial Group of companies to which I am submitting a claim and its authorized representatives, agents and/or employees,
the Plan Sponsor (if self-insured Plan) and other organizations providing claims management services.
Description of the information that may be used or disclosed: This Authorization specifically includes the release of all
information related to:
* My physical and mental health and my insurance policies and claims, including, but not limited to, those containing diagnosis,
treatments, prognosis, prescription drug information, alcohol or drug abuse or information regarding communicable or infectious
conditions, including HIV/AIDS.
* Job duties, earnings, personnel records and other work related information and federal and state tax returns.
* Information concerning Social Security benefits, including any records pertaining to me and my dependents
The information will be used or disclosed only for the following purpose(s): To evaluate and administer my claim, and/or for
insurance-related functions.

STATEMENTS OF UNDERSTANDING AND ACKNOWLEDGMENT:

I understand that information used or disclosed pursuant to this authorization could be subject to redisclosure as necessary by the
recipient and, if so, may not be subject to federal or state law protecting its confidentiality.
I understand that I may revoke this authorization in writing at any time by sending a written revocation to the Company in the
Lincoln Financial Group of companies to which I have submitted a claim, except to the extent that action has been taken in reliance
on this authorization, or to the extent that other law provides the Company with the right to contest a claim. I also understand that
the revocation of this authorization will not affect uses and disclosures of my health information for purposes of treatment, payment
and health care operations.
I understand that authorizing the disclosure of my health information is voluntary and the provision of health care services to me is
not conditioned on whether I sign this authorization. If I choose not to sign this authorization, insurance coverage or claim
payments may be denied or delayed.
This authorization shall remain in force for 24 months from the date of signature, except to the extent applicable state law imposes
or allows a different duration. The information obtained under this authorization will be retained in accordance with the Company's
standard retention policy and applicable law. I understand that I may request a copy of this authorization.

Name of claimant (print) 71.1.6.001

Name of legal representative, if applicable (print) 71.1.6.002 Relationship 71.1.6.003

71.1.1.001

Signature of claimant or legal representative Date: 71.1.2.001

Date of Birth: 09/12/1966 Claim Number: 16193389

A copy of this authorization will be considered as valid as the original.

pg. 1 Authorization-Standard-2020
 Disability Attending Physician Statement
The Lincoln National Life Insurance Company
Disability and Life Claims
PO Box 2578
Omaha, NE 68103-2578
Phone No.: (866) 317-9383
Secure Fax No.: (603) 334-0401

Instructions: All sections below need to be completed by your treating provider. Once complete login to our secure portal
to upload the document, fax to Secure Fax No.: (603) 334-0401, or email to [email protected].

1. Claimant Information
Employee's Name: Richard Albrecht Claim Number: 16193389
Date of Birth: 09/12/1966 Telephone Number: (817) 323-5920 Social Security Number:
Employer Name: HD Supply, Inc.

2. Medical Facts
Primary Diagnosis: 1680.1.6.001 ICD-10 Code: 1680.1.6.002
Secondary Diagnosis: 1680.1.6.003 ICD-10 Code: 1680.1.6.004
Co-Morbids: 1680.1.6.005
Height: 1680.1.6.006 Weight: 1680.1.6.007 Gender: 1680.1.6.008
1680.1.10.003
Is the Disability a Result of:1680.1.10.001
Illness 1680.1.10.002
Injury Work Related

Date Unable to Work: 1680.1.5.001 If Injury, Date of Injury: 1680.1.5.002

Date of Initial Treatment: 1680.1.5.003 Date of Most Recent Treatment: 1680.1.5.004

Date of Next Treatment: 1680.1.5.005 Reoccurring Condition? 1680.1.10.004

Yes 1680.1.10.005
No
Has Patient Been Hospitalized:1680.1.10.006
Yes 1680.1.10.007
No If Yes, Dates of Admission and Discharge:1680.1.5.006 to 1680.1.5.007
Hospitalization Reason: 1680.1.6.009
Has/Will Surgery Occur?1680.1.10.008
Yes 1680.1.10.009
No Surgery Elective?1680.1.10.010
Yes 1680.1.10.011
No Date of Surgery: 1680.1.5.008
Surgery Type: 1680.1.6.010
If Pregnancy: Estimated Due Date: 1680.1.5.009 Actual Delivery Date: 1680.1.5.010
Advised to Cease Work Prior to Delivery:1680.1.10.012
Yes 1680.1.10.013
No Delivery Type: 1680.1.10.014
Vaginal 1680.1.10.015
C-Section
Pregnancy Complications:
1680.1.6.011

Symptoms (including impact to ADL's, and self reported symptoms):

1680.1.6.012

Objective Findings (include copies of x-rays, EKG's, blood work, scans, and any clinical findings):
1680.1.6.013

Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 1 of 4

GLC12544NY-S1 11/23
 Nature of Treatment (current and recommended, frequency) and Treatment/Physician Referrals (include phone/fax
number):
1680.1.6.014

Medications (include dosage, frequency, and dates prescribed/changed):

1680.1.6.015

Restrictions and Limitations:

Mental Diagnosis (Ability to perform task using scale
Physical Diagnosis: below):
1 = Unable to Perform 2 = Markedly Limited
Lifting: 1680.1.6.016 lbs 1680.1.6.017 hours per workday
3 = Somewhat Limited 4 = Unlimited
Carrying:1680.1.6.018 lbs 1680.1.6.019 hours per workday 1680.1.6.029
Perform at Constant Pace:
Maintain Attention/Concentration: 1680.1.6.030
Provide Hours per Work Day:
Comprehend Daily Tasks: 1680.1.6.031
Sitting: 1680.1.6.020 Multi-Task: 1680.1.6.032
Standing: 1680.1.6.021 Communicate Effectively: 1680.1.6.033
Walking: 1680.1.6.022 Regulate EmotIons: 1680.1.6.034
Kneeling: 1680.1.6.023 Follow Instructions: 1680.1.6.035
Climbing: 1680.1.6.024 Interact with Colleagues: 1680.1.6.036
Squatting: 1680.1.6.025 Interact with Public: 1680.1.6.037
Stooping: 1680.1.6.026 Make Decisions: 1680.1.6.038
Bending: 1680.1.6.027 Work Alone/Separate from Others: 1680.1.6.039
Reaching: 1680.1.6.028

Dates of Restrictions and Limitations: 1680.1.5.011 to 1680.1.5.012 Date Able to Return to Work: 1680.1.5.013
Full Time
1680.1.10.016 Part Time
1680.1.10.017 Part Time Days/Hours: 1680.1.6.040
Job Modifications Needed to Return to Work:
Modified Work Schedule: 1680.1.6.041 Duration of Modified Work Schedule: 1680.1.6.042
Additional Restrictions and Limitations:
1680.1.6.043

3. Signature
New York. 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 subject to a civil
penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Printed Name of Provider (including Credentials): 1680.1.6.044

1680.1.1.001
1680.1.2.001
Provider Signature Date
Specialty of Practice: 1680.1.6.045 Address of Practice: 1680.1.6.046
Phone Number: 1680.1.8.001 Fax Number: 1680.1.8.002
Email: 1680.1.6.047
Lincoln Financial Group is not responsible for charges incurred due to completion of this form. The patient is responsible for
any charges associated with form completion. Please see Fraud Notices attached. Page 2 of 4
GLC12544NY-S1 11/23
FRAUD NOTICES. For your protection, certain states require that the following notices appear
on this form.
Alabama. 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.
Alaska. A person who knowingly and with intent to injure, defraud, or deceive an insurance company
files a claim containing false, incomplete or misleading information may be prosecuted under state
law.
Arizona. For your protection Arizona law requires the following statement to appear on this form. Any
person who knowingly presents a false claim for payment of a loss is subject to criminal and civil
penalties.
Arkansas, Louisiana, Rhode Island and West Virginia. 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.
California. For your protection California law requires the following to appear on this form: Any
person who knowingly presents a false or fraudulent information to obtain or amend insurance
coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines
and confinement in state prison.
Colorado. 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 Services.
Delaware. Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files
a statement of claim containing any false, incomplete or misleading information is guilty of a felony.
District of Columbia. 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 applicant.
Florida. Any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a
statement of claim, or an application containing any false, incomplete, or misleading information is
guilty of a felony of the third degree.
Kansas. A person may be guilty of fraud as determined by a court of law, if he or she submits an
application or claim containing a false or deceptive statement with intent to defraud (or knowing that
he or she is helping to defraud) an insurance company.
Kentucky. Any person who knowingly and with the intent to defraud an insurance company or other
person files a 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.
Maine. It is a crime to knowingly provide false, incomplete, or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a
denial of insurance benefits.
Maryland. Any person who knowingly or willfully presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly or willfully presents false information in an application for insurance
is guilty of a crime and may be subject to fines and confinement in prison. Page 3 of 4
GLC12544NY-S1 11/23
New Jersey. Any person who knowingly files a statement of claim containing any false or misleading
information is subject to criminal and civil penalties.
New Mexico. 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.
North Carolina. Any person who, with intent to injure, defraud, or deceive an insurer or insurance
claimant: (1) presents or causes to be presented a written or oral statement, including
computer-generated documents as part of, in support of, or in opposition to, a claim for payment or
other benefit pursuant to an insurance policy, knowing that the statement contains false or
misleading information concerning any fact or matter material to a claim, or (2) assists, abets,
solicits, or conspires with another person to prepare or make any written or oral statement that is
intended to be presented to an insurer or insurance claimant in connection with, in support of, or in
opposition to, a claim for payment or other benefit pursuant to an insurance policy, knowing that the
statement contains false or misleading information concerning a fact or matter material to the claim is
guilty of a Class H felony.
Ohio. Any person who, with intent to defraud or knowing that he is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement is guilty of
insurance fraud.
Oklahoma. 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.
Oregon. A person may be committing insurance fraud, if he or she submits an application or claim
containing a misstatement, misrepresentation, omission or concealment with intent to defraud (or
knowing that he or she is helping to defraud) an insurance company.
Pennsylvania. 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
civil penalties.
Puerto Rico. Any person who knowingly and with the intention of defrauding presents false
information in an insurance application, or presents, helps, or causes the presentation of a
fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for
the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each
violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand
dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should
aggravating circumstances be present, the penalty thus established may be increased to a maximum
of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2)
years.
Tennessee, Virginia, and Washington. 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.
Texas. 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.
Vermont. Any person who knowingly presents a false statement in an application for insurance may
be guilty of a criminal offense and subject to penalties under state law.
FOR ALL OTHER STATES. A person may be committing insurance fraud, if he or she submits an
application or claim containing a false or deceptive statement with intent to defraud (or knowing that
he or she is helping to defraud) an insurance company. Page 4 of 4
GLC12544NY-S1 11/23