Dependent Child'S Statement Of Disability Form - Bluecross Blueshield Of Montana
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1P.O. Box 4309, Helena, MT 59604
Date _______________________
DEPENDENT CHILD’S STATEMENT OF DISABILITY
Group No. _____________________________________ Identification No. __________________________________________
Employee’ s Name _______________________________________________________________________________________
Employee’ s Street Address _________________________________________________________________________________
City ______________________________________________________ State _________ ZIP Code ___________________
Dependent Child’ s Name __________________________________________________________________________________
Social Security No. _______________________________ Relationship _____________________________________________
Dependent Child’ s Place of Residence/Street Address ____________________________________________________________
City ______________________________________________________ State _________ ZIP Code ___________________
Marital Status ___________________________________ Date of Birth _____________________________________________
I hereby authorize any hospital, physician or health care provider who has treated the above dependent child to
furnish medical information that is specific to the dependent’s disability to Blue Cross and Blue Shield of Montana
and HMO Montana®. This authorization will expire one year after the employee’s signature date.
Employee’ s Signature ____________________________________________ Date ____________________________________
TO BE COMPLETED BY ATTENDING PHYSICIAN
NOTE: ANY FEE FOR THE COMPLETION OF THIS FORM IS THE RESPONSIBILITY OF THE PATIENT.
1. Patient’ s Name _______________________________________________________________________________________
2. Diagnosis (Be as detailed as possible) ______________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
3. If dependent child has ever been under observation, care or treatment related to the dependent’ s disability in any hospital,
sanitarium, asylum or similar institution, please complete the following:
Name of hospital or institution ___________________________________________________________________________
Number of days _________________ Date of last treatment or care ______________________________________________
4. Treatment
(a) Date of first visit _________________________________________________________________________
(b) Frequency of visits
Weekly
Monthly
Other
_________________________________
5. Extent of Disability
(a) Is patient now incapable of self-support because of disability?
Yes
No
(b) Disability has existed continuously since _________________________________________________________________
(c) When do you think patient will be able to return to gainful employment?
Approximate Date _______________________
Indefinite
Never
Physician’ s Name _______________________________________________ Phone ___________________________________
Physician’ s Street Address __________________________________________________________________________________
City ______________________________________________________ State _________ ZIP Code ___________________
Physician’ s Signature ____________________________________________ Date ____________________________________
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
350744.0414
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