State Employee/retiree Health Benefits Program Disability Form
ADVERTISEMENT
1State of Maryland
State Employee/Retiree Health Benefits Program
Disability Form
This portion to be completed by Employee/ Retiree.
Employee/Retiree Name:
Employee/Retiree Social Security Number:
Dependent’s Name:
Dependent’s Date of Birth:
Month __________ Day ___________ Year ________
Relationship to Employee/Retiree:
Dependent’s Sex:
Male
Female
Dependent’s Social Security Number:
Dependent’s Marital Status:
Single
Married
Divorced
Separated
Do you chiefly provide the dependent’s support?
Yes
No
Is this dependent a current SSI recipient due to disability?
Yes
No
(Please enclose letter of determination from SSI)
Does this dependent have Medicare A or Part B?
Yes
No
Effective date: ______________
(Please enclose Medicare letter)
________________________________
______________
Signature of Employee/Retiree
Date
This portion to be completed by Physician.
This portion outlines documentation to be submitted by the dependent’s personal physician. Information must be current (i.e. the patient has been
examined within the last 6 months for medical or 3 months for mental health.
Diagnosis: __________________________ Date of onset of condition: _____________________
Prognosis: __________________________
Does this condition impose on the dependent’s ability to perform daily duties or maintain gainful employment?
Yes
No
Is the dependent in an institution?
Yes
No
Name of Institution: ________________________________________________
Name of Physician (please print) ______________________________ Phone Number _______________________
Physician’s Address _______________________________________________________________________________________
_______________________________________________________________________________________
Signature of Physician ________________________________________________________ Date ________________________
For medical disability request, please attach the most recent history and physical, which document the diagnosis and the
functional limitations.
For mental health disability request, please attach the most recent psychiatric evaluation which documents the diagnosis and
the functional limitations
All Protected Health Information provided by your dependent’s physician will be kept confidential in accordance with the
HIPAA law and will only be reviewed for the purpose of determining your dependent’s disability.
Once this form and medical notes are received along with the signed authorization form, we will forward all documentation to the
medical plan for a determination. Please allow 30 days.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal