Disabled Child Attending Physician s Stmt Behvl Hlth Attending Physician s Stmt Disabled Child Atten 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out Section 1, which requires employer information. Enter the name as shown on the ID card and the policy/group number.
3. Proceed to Section 2 for employee information. Fill in your name, ID number, and birth date in MM/DD/YYYY format.
4. In Section 3, provide details about the dependent child, including their name and birth date.
5. For Section 4, the attending physician must complete parts A and B if applicable. This includes diagnosis(es), date of onset, objective findings, and any additional clinical information.
6. Complete Section C by referring to the Social Security disability guidelines to quantify the individual’s disability. Document diagnosis(es) and listing number(s).
7. Fill out Section 5 with the attending physician's contact information and signature, along with the date.
8. Finally, list any other treating physicians in Section 6 who are involved in the individual's care.

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