PLEASE READ CAREFULLY
To determine if your dependent qualies for disabled dependent benets past age 26, completion of this form by the
policyholder and attending physician is required.
DIRECTIONS
1. The policyholder must complete and sign the Disabled Dependent Authorization section.
2. A licensed physician or mental health professional must complete and sign the Disabled Dependent Physician
Certication section. Please complete the form in its entirety, as applicable. If more space is needed, use an
additional sheet of paper or attach copies of medical records/progress notes.
3. Mail the completed form to:
Blue Cross and Blue Shield of Texas
P.O. Box 660044
Dallas, TX 75266-0044
Or fax to: 312-946-3541
Upon completion of the review process, the policyholder and/or their employer group will receive a letter advising of
the determination and coverage dates if applicable. Please allow up to 30 business days for review completion.
If you have questions, please contact customer service using the phone number on your medical insurance ID card.
Disabled Dependent Review Process –
Certication Form
761290.1123
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal
Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Group-Disabled Dependent Certication-2023
2
TO BE FILLED OUT BY THE POLICYHOLDER
1. NAME OF POLICYHOLDER (PRINT – LAST, FIRST & MIDDLE INITIAL) 1A. BLUE CROSS AND BLUE SHIELD OF TEXAS NUMBERS
GROUP MEMBER ID
NUMBER NUMBER
2. POLICYHOLDER'S ADDRESS (NUMBER, STREET, CITY, STATE & ZIP CODE)
3. DEPENDENT'S NAME 3A. DEPENDENT'S BIRTHDATE (MM/DD/YYYY)
/ /
3C. DEPENDENT'S RELATIONSHIP TO POLICYHOLDER 3D. DEPENDENT'S SEX
□
MALE
□
FEMALE
3E. DEPENDENT'S AGE WHEN
DISABILITY OCCURRED
4. IS DEPENDENT PERMANENTLY RESIDING IN YOUR HOUSEHOLD?
IF NO, PLEASE EXPLAIN. IF MORE SPACE IS NEEDED USE AN ADDITIONAL SHEET OF PAPER.
□
YES
□
NO
5. IS THIS PERSON DEPENDENT UPON YOU FOR SUPPORT?
IF YES, WHAT PERCENTAGE OF SUPPORT DO YOU CONTRIBUTE? %
□
YES
□
NO
5A. IS DEPENDENT LISTED AS A DEPENDENT ON YOUR LAST FEDERAL INCOME TAX RETURN?
□
YES
□
NO
6. WAS DEPENDENT EVER EMPLOYED?
□
YES
□
NO
6A. IS DEPENDENT NOW EMPLOYED?
□
YES
□
NO
7. WAS DEPENDENT COVERED UNDER YOUR PRESENT EMPLOYER'S INSURANCE PROGRAM IMMEDIATELY PRIOR TO
REACHING AGE 26?
□
YES
□
NO
8. IS DEPENDENT CONSIDERED DISABLED UNDER SOCIAL SECURITY DISABILITY INSURANCE (SSDI)?
□
YES
□
NO
9. IS DEPENDENT NOW COVERED UNDER MEDICARE OR ANY OTHER HOSPITAL-MEDICAL COVERAGE?
IF YES, PROVIDE NAME OF INSURANCE COMPANY AND GROUP, CERTIFICATE OR AGREEMENT NUMBER.
□
YES
□
NO
INSURANCE COMPANY
GROUP, CERTIFICATE OR AGREEMENT NUMBER
Disabled Dependent
Authorization
When I provide an original or copy of this signed form, I am allowing any medical professional, hospital, clinic, other medical or
medically related facility, governmental agency, or other person or rm to provide Blue Cross and Blue Shield of Texas with
information. This may include copies of records concerning advice, care or treatment provided to the dependent named above,
including, without limitation, information relating to mental illness, use of drugs or alcohol.
I understand that such information will be used by BCBSTX for the purpose of certifying the above named dependent as
disabled for purpose of coverage under my health insurance. I understand that I or any other authorized representative will
receive a copy of this authorization upon request. This authorization to collect medical information is valid from the date signed
for a period of two and one-half years.
I certify that the above information is correct to the best of my knowledge and belief.
761290.1123
SIGNATURE OF POLICYHOLDER DATE SIGNED
P.O. Box 660044, Dallas, TX 75266-0044
Fax: 312-946-3541
3
TO BE FILLED OUT BY THE ATTENDING PHYSICIAN
PATIENT NAME
PHYSICIAN NAME PHYSICIAN PHONE NUMBER
PHYSICIAN ADDRESS
DATE OF FIRST VISIT (MM/DD/YYYY)
/ /
FREQUENCY OF VISITS LAST EXAM DATE (MM/DD/YYYY)
/ /
Disabled Dependent
Physician Certication
P.O. Box 660044, Dallas, TX 75266-0044
Fax: 312-946-3541
NOTE:
Any fee for the completion of this form is the responsibility of the policyholder.
NOTE: Please complete the form in its entirety, as applicable. If more space is needed, use an additional sheet of paper or attach copies of medical records/progress notes.
761290.1123
PRIMARY DIAGNOSIS (REQUIRED)
PHYSICAL: ICD-10 CODES BEHAVIORAL: ICD-10 CODES DATE OF ONSET OF INCAPACITATING DIAGNOSIS (MM/DD/YYYY)
/ /
NATURE OF THE DISABILITY (REQUIRED)
PLEASE DESCRIBE: ETIOLOGY/CAUSE, SEVERITY, CURRENT SIGNS AND SYMPTOMS
DAILY LIVING (REQUIRED)
PLEASE GIVE DETAILS REGARDING: TYPICAL DAY’S ACTIVITY AND DEGREE OF ASSISTANCE NEEDED TO COMPLETE THESE ACTIVITIES
PROVIDE SPECIFIC LIMITATIONS AND THE IMPACT THEY HAVE ON GAINFUL EMPLOYMENT
WHEN DO YOU THINK THE PATIENT WILL BE ABLE TO RETURN TO GAINFUL EMPLOYMENT?
APPROXIMATE DATE: / /
□
INDEFINITE
□
NEVER
FOR MENTAL DISABILITY (IF APPLICABLE)
PHYSICAL & COGNITIVE LIMITATIONS IQ TESTING RESULTS
TREATMENT PLAN (REQUIRED)
INCLUDE PREVIOUS, CURRENT, AND PLANNED TREATMENT; TREATMENT GOALS AND PROJECTED DURATION OF TREATMENT
SECONDARY SUPPORTING DIAGNOSIS (IF APPLICABLE)
CURRENT SIGNS AND SYMPTOMS SECONDARY TO THE DIAGNOSIS
NAME OF PHYSICIAN (PRINT OR TYPE) CREDENTIALS
PHYSICIAN'S SIGNATURE DATE SIGNED