Foundation Payroll Deduction Authorization Medical Mutual (Page 2 of 4) in pdf

MEDICAL MUTUAL AND ITS FAMILY OF COMPANIES

REQUEST TO EXTEND LIMITING AGE FOR DEPENDENT CHILD

SECTION 2 – TO BE COMPLETED BY ATTENDING PHYSICIAN

This report requests evidence of the Disabled Dependents Status of your patient, to assist us in determining eligibility for group coverage beyond

the dependent age limit.

“Disabled Dependent Status” means the incapacity to achieve self-support through employment at a minimum level because of any condition

defined by contract or law as handicap.

Patient Name:

Policyholder SSN:

When did the symptoms first appear or

Date patient became incapacitated by disability.

Has the patient been continuously

accident happen?

incapacitated or mentally disabled?

Yes □

No □

Diagnosis:

Symptoms:

Objective findings (current signs, results of pertinent diagnostic studies):

___________________________________________________________

Nature of treatment (including surgery, therapy, medications, etc):

_________________________________________________________________________________________________________________________

PHYSICAL IMPAIRMENT:

□

Class 1 - No limitation of functional capacity: capable of heavy physical activity. No restrictions. (0-10%)

□

Class 2 - Slight limitation of functional capacity: capable of light manual activity. (15-30%)

□

Class 3 - Moderate limitation of functional capacity: capable of clerical/administrative (sedentary) activity. (35-55%)

□

Class 4 - Marked limitation (50-70%)

□

Class 5 - Severe limitation of functional capacity: incapable of minimal (sedentary) activity. (75-100%)

□

Remarks:

_________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

INTELLECTUAL IMPAIRMENT:

Remarks: ____________________________________________________________________________

□

None (IQ 85 and above)

____________________________________________________________________________________

□

Borderline (IQ 71-84)

□

Mild (IQ 50-70)

____________________________________________________________________________________

□

Moderate (IQ 35-49)

____________________________________________________________________________________

□

Severe/Profound (IQ 34 and below)

Foundation Payroll Deduction Authorization Medical Mutual Page 2

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