MEMBER NAME: DEPENDENT NAME:
Functional Assessment of Activities of Daily Living (ADL): Indicate the patient’s degree of physical or mental
disability in the following ADLs using a scale of 1 to 10. One (1) indicates the ADL is not affected by the patient’s disability.
Ten (10) indicates the patient is completely disabled in this ADL skill or ability. These functional disabilities limit the
patient’s capacity for self-support.
Mobility Skills Self-Care Skills Sensory Skills Cognitive Skills
walking feeding hearing judgment
sitting bathing seeing memory
standing toileting speech planning/follow through
lifting dressing touch thinking/processing information
Psychological / Psychiatric Assessment: List the specific psychological / psychiatric symptoms or behaviors, if
any, that affect the patient’s ADLs and limit his or her capacity to be self-supporting:
PART D, Medical Certification of Disability and Incapacity of Self-Support: For purposes of this benefit, a CalPERS member can
retain his or her eligibility for health benefits as a family member if he or she is unmarried and incapable of self-support (i.e., not
capable of engaging in any substantial gainful activity) due to physical or mental disability which existed continuously prior to becoming
26 years of age.
1. Based upon your examination, does the patient currently have a physically or mentally disabling injury, illness, or condition?
NO, the patient does NOT have a physically or mentally disabling injury, illness or condition.
YES (Please answer Question 2)
2. In your medical or psychiatric opinion, please select A, B, or C:
A The patient’s current disability DOES NOT render him or her incapable of self-support.
B The patient’s current disability DOES render him or her incapable of self-support, but the disability should resolve or
improve sufficiently for the patient to be capable of self-support by .
PROJECTED DATE (mm/yy)
If the condition is likely to improve or resolve, make SOME estimate of when this will occur.
Please DO NOT leave the PROJECTED DATE blank. Answers such as “indefinite” or “don’t know” will not suffice.
C The patient’s current disability is of a permanent or extended duration and, consequently, the patient is not and will not be
capable of self-support within the foreseeable future (e.g., more than 5 years).
I certify that, based upon my examination of the patient, the above statements truly describe the patient’s disability and his
or her capability of self-support, and that I am a ,
(Type of Physician) (Specialty, if any)
licensed to practice by the State of .
PRINT, TYPE or STAMP PHYSICIAN’S NAME AS SHOWN ON LICENSE and HIS OR HER ADDRESS, TELEPHONE AND FAX NUMBERS:
PHYSICIAN’S NAME AS SHOWN ON LICENSE
CITY, STATE ZIP
ORIGINAL SIGNATURE OF ATTENDING PHYSICIAN
STATE LICENSE NUMBER
PART E, CalPERS USE ONLY:
Claim approved for enrollment through
DATE (for next review) REVIEWED BY
HBD-34 Rev 10/17