SSA-604

Certificate Of Incapacity

Download and Print the SSA-604

PART A - TO BE COMPLETED BY EXAMINING PHYSICIAN
The Federal Employees Health Benefits Program covers adult children of an employee's family if they are incapable of self-support because of a physical or mental disability. These children are over the age of 22 whose disabilities existed before age 22. This provision of law has been construed as applying to only the most serious types of disabilities, and then, only if the disability can be expected to continue for at least one year and the child is incapable of self-support
Complete the following only if you have examined the person and consider the person to have such a disability.

1. Name of adult incapacitated child:

2. Diagnosis underlying the disability which makes the child incapable of self-support:

3. Date that this person's disability began:

4. At what age did the condition become so severe that it rendered the child unemployable and incapable of self-support?

5. How long is the child's disability expected to continue?

6. Provide a brief history of the specific medical condition including pertinent findings from previous examinations, test results, treatments, and responses to treatment.

7. List the clinical findings from the most recent physical examination, including results from laboratory or imaging studies and psychological tests, if applicable. You may attach a legible copy of your most recent entry in your medical record instead if it supplies or supports the documentation.

8. Has there been a recent change in the individual's medical condition, including improvement or deterioration? Please explain.

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