Form HBD-98 "Member Questionnaire for the CalPERS Disabled Dependent Health Benefit" - California

What Is Form HBD-98?

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-98 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-98 "Member Questionnaire for the CalPERS Disabled Dependent Health Benefit" - California

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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:_________________________________________
Name:__________________________________________
Social Security Number (SSN): _______-____-________
Social Security Number (SSN):______-_____-______
Address:________________________________________
Address:__________________________________________
Primary Phone Number: (____)_____________________
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.
Is the dependent entitled to:
Yes
No
Medicare Part A (hospital care)? (If yes, attach a copy of the dependent’s Medicare card.)
Yes
No
Medicare Part B (medical care)? (If yes, attach a copy of the dependent’s Medicare card.)
Yes
No
Other insurance? (If yes, specify the plan name and type of coverage.)
Income and Support
2.
Is the dependent economically dependent upon you for his or her support?
Yes
No
I claim the child as my dependent for income tax purposes.
Yes
No
3.
Is the dependent entitled to receive:
Yes
No
Social Security Disability Insurance (SSDI)? If yes, as of what date? ____________
Yes
No
Supplemental Security Income (SSI)? If yes, as of what date?
____________
Additional Eligibility Questions
4.
Yes
No
Is the dependent working?
Yes
No
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
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:_________________________________________
Name:__________________________________________
Social Security Number (SSN): _______-____-________
Social Security Number (SSN):______-_____-______
Address:________________________________________
Address:__________________________________________
Primary Phone Number: (____)_____________________
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.
Is the dependent entitled to:
Yes
No
Medicare Part A (hospital care)? (If yes, attach a copy of the dependent’s Medicare card.)
Yes
No
Medicare Part B (medical care)? (If yes, attach a copy of the dependent’s Medicare card.)
Yes
No
Other insurance? (If yes, specify the plan name and type of coverage.)
Income and Support
2.
Is the dependent economically dependent upon you for his or her support?
Yes
No
I claim the child as my dependent for income tax purposes.
Yes
No
3.
Is the dependent entitled to receive:
Yes
No
Social Security Disability Insurance (SSDI)? If yes, as of what date? ____________
Yes
No
Supplemental Security Income (SSI)? If yes, as of what date?
____________
Additional Eligibility Questions
4.
Yes
No
Is the dependent working?
Yes
No
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
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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