Impaired Dependent Certification printable pdf download

Impaired Dependent Certification

New Mexico Public Schools

Insurance Authority

Impaired Dependent Certification

Complete this form and return to your employer’s benefit office if the following situation applies to you:

Your dependent who is mentally or physically impaired is 25 years old and currently on your health plan. Please submit

this form the month before your dependent turns age 26.

Part 1

(To be completed by Employee)

Employee’s Last Name, First, Middle Initial

Employee’s Social Security Number

Mailing Address

Dependent’s Last Name, First, Middle Initial

Dependent’s Date of Birth:

Dependent’s Marital Status

 Single

 Married

 Widowed

 Divorced

When did the impaired status occur? ____________________

Provide details: _____________________________________________________________________________

__________________________________________________________________________________________

 Yes

 No

Is dependent reliant on you for support?

If yes, what percentage of support do you contribute?

 Yes

 No

 Yes  No

Was dependent ever employed?

Is dependent employed now?

(If yes, write name and address of current or last employer.)

Summary of any institutional care (names of institutions and dates):

Nature of care:

I hereby declare that all statements and answers to the above questions are complete and true.

Signature of Employee:

Date:

Part II

(To be completed by the attending physician) (List multiple physicians on separate sheet of paper)

Note: The applicant is responsible for the completion of this form without expense to the insurance carrier.

Is this dependent incapable of self-sustaining employment

May the dependent be employed in the future?

because of mental or physical impairment?  Yes

 No

 Yes

 No

 Questionable

Nature and cause of incapacity:

Date of onset:

Prognosis:

Please indicate results of any intelligence test:

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pubsformslarge_group mpsia_depencert.doc

Impaired Dependent Certification

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