CalChoice Disabled Dependent

After completing Section A, please forward this form to your physician for his or her completion
Company Name
Employee First Name
MI
Employee Last Name
Employee Social Security
Employee Address
Apt
City
State
ZIP Code
Dependent Name

Dependent First NameDependent Last Name
Date Disabling Condition Occurred MMDDYYYY

MonthDayYear
Date
Dependent Date of Birth MMDDYYYY

MonthDayYear
Date
Dependent Marital Status
Does the dependent reside in your home?

YesNo
Is he or she more than 50% dependent upon you for support?

YesNo
Is he or she listed as dependent on your last income tax return?

YesNo
Is dependent employed?

YesNo
If yes date of hire MMDDYYYY

MonthDayYear
Date
Number of hours Employed per week
Describe nature of duties
| certify that the above information is correct and authorize the release of medical information requested with respect to this certification
Print Name
Employee Signature

Clear
Date MMDDYYYY

MonthDayYear
Date
SECTION B - To be completed by attending physician A dependent child who is incapable of self-support due to a continuously disabling illness or injury may be continued as a family member on the parent's health coverage. Your medical statement will help us determine the eligibility of this dependent.
Please give us the specifics as to the nature of the disability attach supporting documentation
To what extent does the disability limit normal activity attach supporting documentation
What is your prognosis including your estimates of length of time this disability may be expected to continue attach supporting documentation
Physician Signature

Clear
Print Name
Date MMDDYYYY

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState

ZIP Code
DO NOT SUBMIT! VIEW AND PRINT AND FORWARD THIS FORM TO YOUR PHYSICIAN FOR COMPLETION.

Use the Must Print button to Print to have the physician sign the form. This form must be uploaded.

Holistic Employee Benefits

License# 0770042

(866) 417-3863
Save and Continue Later if you'd like to start the form on your computer and sign with your phone. You'll receive a link by email to complete the signature and submit it later.
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