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The document is a Disabled Dependent Certification form that requires completion by both the subscriber and the attending physician. It collects information about the subscriber, their dependent, and the dependent's disabling condition to determine eligibility for continued medical coverage under the parent's plan. The physician must provide details regarding the disability, its impact on normal activities, and prognosis.

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Versions	Form popularity	Fillable & printable
2013	4.7 Satisfied (59 Votes)
2008	4 Satisfied (33 Votes)

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What is Government of Canada Form 2165?

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