Form SSA-604 Certificate of Incapacity

Form Approved
OM6 No. 0960-XXXX

Certificate of Incapacity

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

6. List the clinical findinas from the most recent ~hvsicalexamination, including results from
laboratory or imagingstudies and psychologi&l;ests,
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.

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

Form SSA-604 (X-2006)

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8. List any special supervisory, physical assistance, or custodial care that the individual now
requires.

9. List any treatments, rehabilitation programs, educational training or occupational

accommodations that could help the child become self-supportive.

10. Additional comments:

I certify that the adult child listed on this certificate is incapable of self-support due to the
above disability. Ideclare under penalty of perjury that I have examined all the information on
this form, and on any accompanying statements or forms, and it is true and correct to the
best of my knowledge.

Doctor's Name:

Date:

Doctor's Signature:
Office Address:
Office Telephone Number:

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PART B -TO BE COMPLETED BY EMPLOYEE
1. Employee's name and mailing address:

2. Employee's social security number:
3. Health benefit plan code:
4. Adult child's relationship to employee:

5. Child's date of birth:
6. Has the child been employed during the last twelve months? If so, provide name of employer,
periods of employment, description of work performed, and total earnings:

7. If employed, was employment in a closely Supervised environment such as a sheltered
workshop?

8. List highest level of education of disabled child:
Form SSA-604 (X-2006)

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Privacy Act Statement

We are required by 5 U.S.C. 5 8901 to ask you to give us the information on this form. The
information is needed to determine whether your adult disabled child is eligible for health care
benefits under the Federal Employee Health Benefits Program (FEHB) beyond age 22. Although
the responses on this form are voluntary, failure to provide the requested information will result in
automatic termination of the health care benefits at age 22.
The information obtained on this form is almost never used for any purpose other than that stated
above. However, sometimes the law requires us to disclose the facts on this form without your
consent. For example, it may also be disclosed to another government agency if federal law
requires that we do so or to contractors, as necessary, to assist in the efficient administration of the
FEHB Program.
Explanations about the reasons why information you provide us may be used or given out are
available in servicing personnel offices. If you want to learn more about this, contact your local
servicing personnel office.
Paperwork Reduction Act Statement - This information collection meets the requirements of 44
U.S.C. 5 3507, as amended by section 2 of the P a ~ e w o r kReduction Act of 1995. You do not need
to answer these questions unless we displa valid Office of Management and Budget control
m~nutesto read the instructions, gather the facts, and
number. We estimate that it will take abou
answer the questions. You may send comments on our time estimate above to: SSA, 6401
Security Blvd., Baltimore, MD 21235-6401. Send&
comments relating to our time
estimate to this address, not the completed form.

!+A,

Form SSA-604 (X-2006)

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