Fillable Application For Intellectual Disability (Blue Cross Blue Shield of North Dakota)

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Application For Intellectual Disability (Blue Cross Blue Shield of North Dakota)

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The Application For Intellectual Disability (Blue Cross Blue Shield of North Dakota) form is 3 pages long and contains:

  • 2 signatures
  • 14 check-boxes
  • 71 other fields

Country of origin: US
File type: PDF

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Page 1 of 3
29310279 • 8-19
Member Information
Unique Member Identifier
Dependent’s Name Social Security Number
Medicare ID Card Number
Hospital Part A Eective Date Medical Part B Eective Date Prescription Drug Part D Eective Date
0 1
0 1
0 1
Subscriber’s Statement – To Be Completed By Subscriber
1. Does dependent reside at the home of the subscriber?
Yes
No – If no, why? (ie. divorce decree, group home, residential facility)
Address of dependent:
Address City State Zip Code
2. Is the dependent claimed on the subscriber’s federal tax income return?
Yes
No
3. Is the dependent unmarried?
Yes
No
4. Is the dependent capable of ANY employment?
Yes
No
If yes, is the dependent employed?
Yes
No
Where:
Job description:
Number of hours per week:
Method of transportation to and from job (drives car, uses public transportation, uses special van
(ie. “Handiwheels”, etc.):
5. Does dependent have a diagnosis of intellectual disability?
Yes
No
6. Does dependent have a diagnosis of physical disability?
Yes
No
7. Does dependent have a diagnosis of any seizure disorder?
Yes – If yes, when was the last seizure?
No
Medication, dose and frequency:
Number of seizures per day:
8. Does dependent attend school?
Yes – If yes, Where?
No
What grade level:
Mainstream (in non special education class) experience:
Application For Intellectual Disability
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Noridian Mutual Insurance Company
Page 2 of 3
29310279 • 8-19
Subscriber’s Statement – To Be Completed By Subscriber
9. Is dependent blind and/or deaf?
Yes – Blind
Yes – Deaf
No
If yes, does/did the dependent attend special education for the disability?
Yes
No
10. Was the dependent born with the disability?
Yes
No
11. Was the disability acquired?
Yes
No
If yes:
Where:
When:
How:
12. What is the dependent’s level of activity for Activities of Daily Living (ADL’s)?
Needs complete assistance in feeding, dressing, etc.
Needs partial assistance in feeding, dressing, etc.
Needs mental cueing to do activity
Needs assistance for mobility, does most ADL’s independently (ie. needs assist to wheelchair, car, bed)
13. What is the expected date of improvement in condition or recovery?
Disability is considered permanent
Disability is of a nature that dependent status MIGHT change after sucient education, and training
Disability is of a nature that dependent status WILL change after sucient education, and training
Page 3 of 3
29310279 • 8-19
Physician Statement – To Be Completed By The Attending Physician
This is to certify that __________________________________________________________________
has the specific diagnosis(es) (ICD-10)
This dependent is receiving the following medications:
The disability is of a permanent nature (ie. anacephalic, quadriplegia, intellectual disability) such that
the dependent is incapable of self-support because of the intellectual disability or physical disability.
This disability prevents him or her from engaging in ANY occupation or employment. (Be specific)
The disability is of a partial nature (ie. blind, deaf, mild intellectual disability, etc.) (Be specific)
There is potential for independent living with appropriate education at sometime in the future
I hereby authorize Doctor ____________________________________ to complete this form and forward it to:
• Blue Cross Blue Shield of North Dakota
4510 13th Avenue South
Fargo, North Dakota 58121
Subscriber Signature Date (mm/dd/yyyy)
Subscriber Address City State Zip Code
Physician Signature Date (mm/dd/yyyy)
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Application For Intellectual Disability (Blue Cross Blue Shield of North Dakota)

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Completed 10 June 2021

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