Form HBD-34 "Medical Report for the CalPERS Disabled Dependent Benefit" - California

What Is Form HBD-34?

This is a legal form that was released by the California Public Employees' Retirement System - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2017;
  • The latest edition provided by the California Public Employees' Retirement System;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HBD-34 by clicking the link below or browse more documents and templates provided by the California Public Employees' Retirement System.

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Download Form HBD-34 "Medical Report for the CalPERS Disabled Dependent Benefit" - California

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a
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
MEDICAL REPORT for the CalPERS DISABLED DEPENDENT BENEFIT
COMPLETE ALL ITEMS. INCOMPLETE FORMS WILL BE RETURNED CAUSING DELAY IN BENEFITS.
MEMBER PART A: The member is to complete the information in Part A:
MEMBER INFORMATION
DEPENDENT INFORMATION
NAME:
NAME:
SOCIAL SECURITY NUMBER (SSN):
SOCIAL SECURITY NUMBER (SSN):
ADDRESS:
ADDRESS:
PRIMARY PHONE NUMBER:
DATE OF BIRTH:
PART B, DEPENDENT AUTHORIZATION: The dependent, or person authorized to act in his or her behalf, is to complete the
information requested in PART B prior to giving the form to the physician for completion:
I hereby authorize my attending physician,
, to furnish and disclose all facts
concerning my disability that are within his or her knowledge and to allow inspection, and provide copies, of any medical records
concerning my disability that are under his or her control. This authorization shall be valid for a period of one year from the date of my
signature or the effective date of this claim, whichever is later. I agree that a photocopy of this authorization shall be as valid as an
original. I understand that if I do not sign this authorization, or if I revoke or modify it, CalPERS may not be able to determine my
eligibility as a disabled dependent and that my request may be denied. I also understand that CalPERS will keep confidential the
information which is provided pursuant to this authorization, and that it will be used solely to determine and act upon my request for this
benefit.
Signature of Dependent OR
Date Signed
Person authorized to act on his/her behalf
Relationship to the dependent
PHYSICIAN PART C: The physician is to complete all requested information in PARTS C and D. All responses must be legible. Mail
this completed form to CalPERS at the address found at the top of this page.
Please DO NOT send information copied directly from the patient’s medical record at this time.
Dear Doctor:
The patient requests you to complete this Medical Report form. It will assist CalPERS in processing his or her claim for health
insurance as a disabled dependent under his or her parent’s or guardian’s health plan. By providing the medical information promptly,
you will help the patient expedite the claims process.
Medical Report
1. I attended the patient for the current disabling medical problem or condition from
to
;
at intervals of
. I last examined the patient on
.
2. Medical History (related to disability): Date of Disability Onset:
3. Diagnosis (REQUIRED):
ICD-9 Disease Code, Primary (Required):
ICD-9 Disease Code(s), Secondary:
DSM IV Code(s) (if any):
4. Objective Clinical Findings/Detailed Statement of Symptoms: (see page 2, Items 6 and 7 for additional findings)
5. Current Treatment(s) and /or Medication(s) (rendered to the patient for this disability):
The patient is not currently receiving treatment(s) and/or medications for this disability. (Check if applicable.)
HBD-34 Rev 10/17
a
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
MEDICAL REPORT for the CalPERS DISABLED DEPENDENT BENEFIT
COMPLETE ALL ITEMS. INCOMPLETE FORMS WILL BE RETURNED CAUSING DELAY IN BENEFITS.
MEMBER PART A: The member is to complete the information in Part A:
MEMBER INFORMATION
DEPENDENT INFORMATION
NAME:
NAME:
SOCIAL SECURITY NUMBER (SSN):
SOCIAL SECURITY NUMBER (SSN):
ADDRESS:
ADDRESS:
PRIMARY PHONE NUMBER:
DATE OF BIRTH:
PART B, DEPENDENT AUTHORIZATION: The dependent, or person authorized to act in his or her behalf, is to complete the
information requested in PART B prior to giving the form to the physician for completion:
I hereby authorize my attending physician,
, to furnish and disclose all facts
concerning my disability that are within his or her knowledge and to allow inspection, and provide copies, of any medical records
concerning my disability that are under his or her control. This authorization shall be valid for a period of one year from the date of my
signature or the effective date of this claim, whichever is later. I agree that a photocopy of this authorization shall be as valid as an
original. I understand that if I do not sign this authorization, or if I revoke or modify it, CalPERS may not be able to determine my
eligibility as a disabled dependent and that my request may be denied. I also understand that CalPERS will keep confidential the
information which is provided pursuant to this authorization, and that it will be used solely to determine and act upon my request for this
benefit.
Signature of Dependent OR
Date Signed
Person authorized to act on his/her behalf
Relationship to the dependent
PHYSICIAN PART C: The physician is to complete all requested information in PARTS C and D. All responses must be legible. Mail
this completed form to CalPERS at the address found at the top of this page.
Please DO NOT send information copied directly from the patient’s medical record at this time.
Dear Doctor:
The patient requests you to complete this Medical Report form. It will assist CalPERS in processing his or her claim for health
insurance as a disabled dependent under his or her parent’s or guardian’s health plan. By providing the medical information promptly,
you will help the patient expedite the claims process.
Medical Report
1. I attended the patient for the current disabling medical problem or condition from
to
;
at intervals of
. I last examined the patient on
.
2. Medical History (related to disability): Date of Disability Onset:
3. Diagnosis (REQUIRED):
ICD-9 Disease Code, Primary (Required):
ICD-9 Disease Code(s), Secondary:
DSM IV Code(s) (if any):
4. Objective Clinical Findings/Detailed Statement of Symptoms: (see page 2, Items 6 and 7 for additional findings)
5. Current Treatment(s) and /or Medication(s) (rendered to the patient for this disability):
The patient is not currently receiving treatment(s) and/or medications for this disability. (Check if applicable.)
HBD-34 Rev 10/17
MEMBER NAME:
DEPENDENT NAME:
SSN:
SSN:
Medical Report
Functional Assessment of Activities of Daily Living (ADL): Indicate the patient’s degree of physical or mental
6.
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
bending
7. 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
ORIGINAL SIGNATURE OF ATTENDING PHYSICIAN
LOCAL ADDRESS
STATE LICENSE NUMBER
(
)
PHONE NUMBER
CITY, STATE ZIP
(
)
DATE
FAX NUMBER
PART E, CalPERS USE ONLY:
Claim approved for enrollment through
DATE (for next review)
REVIEWED BY
Claim rejected.
DATE
HBD-34 Rev 10/17
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
Social Security numbers are used for the
following purposes:
The information requested is collected pursuant
1. Enrollee identification
to the Government Code (sections 20000 et seq.)
2. Payroll deduction/state contributions
and will be used for administration of Board
3. Billing of contracting agencies for employee/
duties under the Retirement Law, the Social
employer contributions
Security Act, and the Public Employees’ Medical
4. Reports to CalPERS and other state agencies
and Hospital Care Act, as the case may be.
5. Coordination of benefits among carriers
Submission of the requested information is
6. Resolving member appeals, complaints,
mandatory. Failure to comply may result in
or grievances with health plan carriers
CalPERS being unable to perform its functions
regarding your status.
Information Disclosure
Please do not include information that is
Portions of this information may be transferred
not requested.
to other state agencies (such as your employer),
physicians, and insurance carriers, but only
Social Security Numbers
in strict accordance with current statutes
regarding confidentiality.
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS’
Your Rights
first request for disclosure of your Social Security
number, then disclosure is mandatory. If your
You have the right to review your membership
Social Security number has already been provided,
files maintained by the System. For questions
disclosure is voluntary. Due to the use of Social
about this notice, our Privacy Policy, or your rights,
Security numbers by other agencies for
please write to the CalPERS Privacy Officer at
identification purposes, we may be unable to
400 Q Street, Sacramento, CA 95811 or call us
verify eligibility for benefits without the number.
at 888 CalPERS (or 888-225-7377).
May 2016
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