Handicapped Child Attending Physician's Statement/
Behavioral Health Attending Physician’s Statement
Please print the information requested, with the exception of the signature section.
Employee Instructions:
Attending Physician Instructions:
Complete sections 1-3.
Complete sections 4-6 and return the completed form to the employee.
1. Employer Information
Name (as shown on ID card)
Policy/Group Number
2. Employee Information
Name
ID Number
Birth Date (MM/DD/YYYY)
3. Dependent Child Information
Name
Birth Date (MM/DD/YYYY)
4. Physician’s Statement
For medical conditions, please complete section A below.
For behavioral health conditions, please complete sections A and B below.
For all conditions, you may refer to section C below, Use of the Social Security Disability Guidelines, to quantify an individual’s
disability or handicap.
A. Medical and Behavioral Health conditions:
I.
Diagnosis(es):
U
II.
Date of onset of the handicap:
U
III. Objective findings that substantiate impairment:
U
U
U
IV. Please provide any additional clinical information that supports how the individual’s handicap prevents employment
(applicable to individuals over age 18):
U
U
U
B. Behavioral Health conditions , please provide:
I.
The individual’s IQ score
and,
U
U
II.
A functional assessment. Include communication ability, presence of intrusive psychiatric symptoms, stability,
response to treatment and prognosis (continue on a separate page if necessary):
U
U
U
U
C. Use of the Social Security Disability Guidelines:
To quantify an individual’s disability or handicap, refer to the Social Security disability guidelines found at:
w ww.ssa.gov/disability/professionals/bluebook/ChildhoodListings.htm
(for dependents age 18 and younger) OR
H
H
(for dependents over age 18).
Using the appropriate set of guidelines, select the individual’s affected body system(s). If your patient qualifies, please document the
corresponding “listing” from the guidelines under which the handicap(s) falls.
Note: Satisfying the Social Security listing level impairment requirements does not ensure a determination of disability or handicap
under the individual’s Aetna plan. These Guidelines are only offered as a means to solicit submission of appropriate clinical
information.
Documentation on this form should include:
I.
Diagnosis(es):
U
II.
Listing number(s):
U
Documents and medical records showing how the individual qualifies under a Social Security Disability listing must be submitted with
this form.
5. Attending Physician Contact Information (required)
Attending Physician's Name, Telephone Number and Address (include street, city, state, zip code)
Attending Physician's Signature (required)
Date
6. Other Treating Physicians
Please list the name, address and telephone number of other physicians or other health care providers you are aware of who are currently treating this
individual for his or her mental or physical incapacity.
GC-464 (2-12) A-POD
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