Get Medical Report For The Calpers Disabled Dependent Benefit Form. Medical Report For The Calpers

This guide provides clear instructions for completing the Medical Report For The CalPERS Disabled Dependent Benefit Form. Understanding each section and how to accurately fill it out is critical for timely processing of benefit claims.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. In Part A, begin by filling in the member information. This includes the member's name, social security number, address, telephone number, and date of birth.
3. Next, provide the dependent information below the member information. Fill in the dependent's name, social security number, address, telephone number, and date of birth.
4. In Part B, the dependent or authorized person must complete the authorization section. This includes the name of the attending physician and signing and dating the authorization for medical information disclosure.
5. Part C is intended for the physician. The physician must provide detailed medical information regarding the patient's current condition, medical history, diagnosis, clinical findings, treatment plans, and any medications related to the disability.
6. The physician also needs to assess and report the patient's ability to perform activities of daily living. This includes marking the level of disability on a scale of 1 to 10 in areas such as mobility skills and self-care skills.
7. The physician will also complete the psychological or psychiatric assessment section, noting any symptoms affecting the patient’s ability to be self-supporting.
8. In Part D, the physician must indicate whether the patient has a disabling condition and select the appropriate option describing the patient's capability of self-support.
9. Finally, the physician should provide their credentials, including name, medical license, and contact information, and sign the form.
10. Once all sections of the form are completed, review the document for accuracy. Users can then save changes, download, print or share the form as needed.

Complete your documents online efficiently and ensure timely processing of your benefits.