Get CA Chronic Illness Verification Form 2017-2024

What is the purpose of the Chronic Condition Verification form? It authorizes the plan to contact the provider identified on the form in order to verify that the consumer has at least one of the qualifying chronic conditions covered by the CSNP.

The Chronic Illness Form allows parents to excuse absences due to a specific medical condition with the same authority as a medical professional. Below are guidelines for completing the form correctly to establish and maintain this authorization.

In order to qualify for continued enrollment in this plan, CMS requires verification from a health care provider that the individual has been diagnosed with one or more of the plan-qualifying chronic conditions.

By signing this form, you confirm the patient has been diagnosed with one or more of the following severe or disabling chronic conditions.

Pages in this section Alcohol AbuseDrug Abuse/ Substance AbuseChronic Kidney DiseaseOsteoporosisChronic Obstructive Pulmonary DiseaseSchizophrenia and Other Psychotic DisordersDepressionStrokeDiabetes6 more rows • Sep 6, 2023

15 SNP-Specific Chronic Conditions: Chronic alcohol and other drug dependence. Autoimmune disorders limited to: Polyarteritis nodosa. ... Cancer, excluding pre-cancer conditions or in-situ status. Cardiovascular disorders limited to: Cardiac arrhythmias. ... Chronic heart failure. Dementia. Diabetes mellitus. End-stage liver disease.