Form D-1 - Disability Certification For Dependent Children
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1HAWAII EMPLOYER-UNION HEALTH BENEFITS TRUST FUND (EUTF)
DISABILITY CERTIFICATION FOR DEPENDENT CHILDREN
PHYSICIAN’S STATEMENT
I certify I examined _________________________________________, birth date ________________
and found (him)(her) to be incapable of self-support because of a mental or physical incapacity which began on
________________________
before (he)(she) reached age 19.
(approximate date),
Will be incapable of self-support for the duration of (his) (her) life, or
In my opinion, the above person:
May become self-supporting if (he) (she) responds to treatment
Approximate date of recovery ____________________________
Physician Name: ______________________________________ Tel. No. ___________________________
Address: _______________________________________________________________________________
Signature: ______________________________________________ Date: _________________________
PARENT’S STATEMENT
I certify that the above person meets all of the criteria below:
Is my child
Is incapable of self-support because of a mental or physical incapacity and the incapacity occurred prior
to age 19
Is not married
FOR RETIREES ONLY
Is eligible for Medicare Parts A & B (EUTF requires enrollment in Part B if eligible)
Check one:
•
My child’s Medicare card is attached to this form.
Is not eligible for Medicare Parts A & B.
•
A completed General Affidavit attesting to the fact that he/she is not eligible for
Medicare is attached.
I hereby request he/she be continued as a family member under my EUTF benefit plans. I agree to submit
additional proof of disability as often as required by the EUTF or its insurance carriers. I will notify EUTF of all
changes to the above criteria. I authorize the EUTF and its insurance carriers to use the above information only in
compliance with federal and Hawaii laws governing the privacy of health information.
I hereby declare the above statements are true to the best of my knowledge and belief and I understand that I am
subject to penalty for perjury.
Employee/Retiree Name (Parent): ______________________________________________________________
Address: __________________________________________________________________________________
Phone No._______________________________
SSN: XXX-XX-______________ (last 4 digits)
___________________________________________________
_______________________
Parent’s Signature
Date
Form D-1 (Rev. 4.7.16)
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