Physician’s Statement of Disability

Physician’s Statement of Disability
Please Note: This form must be signed or cosigned by an MD, DO, or the equivalent. The form must be accompanied by a Request for Continuation of Coverage for Disabled Children, to be filled out by the participant/member. The participant/member will get an email to fill out their form, once this form is completed.
Participant/Member Email Address
example@example.com
Member ID
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
A patient is disabled if he/she cannot engage in any substantial gainful activity because of a physical or mental condition that has lasted or can be expected to last continuously for at least a year or can lead to death.

Please choose one for each below.
1. Is the patient prohibited from engaging in any substantial gainful activity because of a physical or mental condition?
2. Has the patient’s condition lasted or can be expected to last continuously for at least a year or lead to death?
3. Is there is any reasonable probability that the patient will ever be capable of self-support?
Please answer the below.
D. Please state the patient’s physical and/or psychological diagnosis.
E. How long has the patient been under your ongoing treatment?
F. What is the patient’s anticipated future course and duration of treatment?
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: