Loading
Get Premera Blue Cross Disabled Dependent Form
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Premera Blue Cross Disabled Dependent Form online
Filling out the Premera Blue Cross Disabled Dependent Form online can be straightforward with the right guidance. This form is essential for determining if your dependent child qualifies for continued coverage after reaching age limits due to their disability.
Follow the steps to complete the form accurately and efficiently.
- Click the ‘Get Form’ button to access the form and open it in your preferred editor.
- In the first section titled 'Employee—Complete This Part,' provide your member ID, group number, and personal information. Include your last name, first name, street address, city, state, ZIP, and the birthdate of your dependent. Make sure to accurately state the relationship to the employee.
- Continue by indicating if your dependent is covered by Medicare and whether they reside with you. If they do not reside with you, provide an explanation.
- In the next fields, answer questions about your support for the dependent, whether they are chiefly dependent on you for maintenance, and if you have legal guardianship if they are 18 or older. Collect necessary documentation if needed.
- Provide employment information if the dependent has been employed. Include the employer's name, address, position held, and dates of employment.
- In the second section, titled 'Physician—Complete Below,' the physician will fill out the details about the dependent's disability. They must determine if the dependent is incapable of self-sustaining employment due to their disability.
- The physician should provide an attached letter containing detailed information regarding the disability, including treatment and relevant medical records from the past 12 months.
- After completing the form, review all entries for accuracy and completeness. Ensure signatures from both you and the physician are included, along with any necessary documentation.
- Once finalized, save the changes to the document. You may choose to download, print the completed form, or share it as required before submitting it to Premera Blue Cross.
Begin filling out the Premera Blue Cross Disabled Dependent Form online today to ensure your dependent receives the coverage they need.
To claim a disabled dependent, you need to complete the Premera Blue Cross Disabled Dependent Form. This form requires detailed information about the dependent’s disability and your relationship to them. Submitting this form accurately will help you secure the necessary benefits and ensure your disabled dependent receives the support they need.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.