______________________________________ _________________
C
Health Account Management Division
P.O. BOX 942715, Sacramento, CA 94229-2715
888 CalPERS (or 888-225-7377) | TTY (877) 249-7442
FAX (800) 959-6545 | www.calpers.ca.gov
MEMBER QUESTIONNAIRE for the CalPERS DISABLED DEPENDENT
HEALTH BENEFIT
Member: Please complete all items. Incomplete forms will be returned causing a delay in benefits
. CalPERS will determine
eligibility upon receipt of this form and the physician’s
MEDICAL REPORT for the DISABLED DEPENDENT BENEFIT.
PART A: EMPLOYEE/ANNUITANT INFORMATION: DEPENDENT INFORMATION:
Name:_________________________________________
Social Security Number (SSN): _______-____-________
Address:________________________________________
Primary Phone Number: (____)_____________________
Name:__________________________________________
Social Security Number (SSN):______-_____-______
Address:__________________________________________
Date of Birth: ______________________________________
PART B: Please provide the following information about the dependent who is seeking initial or continued enrollment or
recertification in the health plan under the disabled dependent benefit. For purposes of this benefit, a person is considered
disabled if the person is incapable of self-support (i.e., incapable of any substantial gainful activity) as a result of a physical
or mental disabling injury, illness or condition. Mail this completed form to the above address.
MEMBER
QUESTIONNAIRE
Health Insurance
1.
Yes
Yes
Yes
No
No
No
Is the dependent entitled to:
Medicare Part A (hospital care)? (If yes, attach a copy of the dependent’s Medicare card.)
Medicare Part B (medical care)? (If yes, attach a copy of the dependent’s Medicare card.)
Other insurance? (If yes, specify the plan name and type of coverage.)
Income and
Support
2.
Yes
Yes
No
No
Is the dependent economically dependent upon you for his or her support?
I claim the child as my dependent for income tax purposes.
3.
Yes
Yes
No
No
Is the dependent entitled to receive:
Social Security Disability Insurance (SSDI)? If yes, as of what date? ____________
Supplemental Security Income (SSI)? If yes, as of what date? ____________
Additional Eligibility Questions
4. Yes
Yes
No
No
Is the dependent working?
Is the dependent incapable of self-support because of a physical or mental disability?
If yes, what age did the dependent become physically or mentally disabled? _____
PART C:
CERTIFICATION:
I hereby certify under penalty of perjury, that information provided by me is true and correct to the best of my
knowledge. I also agree to provide supporting documentation such as, but not limited to, tax returns, statement of
financial liability, or any other documents, when requested by my employer or CalPERS.
Employee/Annuitant Signature Date
HBD-98 Rev 10/17
