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Disabled Child Attending Physician s Stmt Behvl Hlth Attending Physician s Stmt Disabled Child Atten 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling out Section 1, which requires employer information. Enter the name as shown on the ID card and the policy/group number.
- Proceed to Section 2 for employee information. Fill in your name, ID number, and birth date in MM/DD/YYYY format.
- In Section 3, provide details about the dependent child, including their name and birth date.
- 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.
- Complete Section C by referring to the Social Security disability guidelines to quantify the individual’s disability. Document diagnosis(es) and listing number(s).
- Fill out Section 5 with the attending physician's contact information and signature, along with the date.
- Finally, list any other treating physicians in Section 6 who are involved in the individual's care.
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