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  • Premera Blue Cross Disabled Dependent Form

Get Premera Blue Cross Disabled Dependent Form

You or your physician may submit the information along with the completed and signed form to the following address Premera Blue Cross Membership Billing MS 737 PO Box 3048 Spokane WA 99220 Our medical department will review this information for a determination of future coverage. If additional medical information is required we will contact you or the physician. If you have questions about the form please call Customer Service at 800-722-1471. 00.

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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.

  1. Click the ‘Get Form’ button to access the form and open it in your preferred editor.
  2. 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.
  3. 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.
  4. 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.
  5. Provide employment information if the dependent has been employed. Include the employer's name, address, position held, and dates of employment.
  6. 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.
  7. The physician should provide an attached letter containing detailed information regarding the disability, including treatment and relevant medical records from the past 12 months.
  8. 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.
  9. 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.

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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.

VA Form 21P-4171 is a form used by veterans to declare dependents who are disabled and require assistance. Although it differs from the Premera Blue Cross Disabled Dependent Form, both forms serve to certify dependency status for different purposes. If you are a veteran with disabled dependents, ensuring that you fill out the correct form is crucial for receiving appropriate benefits.

The specific form for disabled dependents is the Premera Blue Cross Disabled Dependent Form. This form collects information about your dependent’s disability, which is crucial for them to be recognized as dependents under your insurance plan. Properly completing and submitting this form ensures access to essential healthcare benefits.

Certain individuals cannot be claimed as dependents, including those who earn significant income or those who are not financially reliant on you. This often includes roommates or friends who do not meet the criteria for dependency. It’s essential to understand these limitations when filling out the Premera Blue Cross Disabled Dependent Form to ensure you are compliant with insurance guidelines.

A dependent adult is typically defined as someone who is over 18 and relies on someone else for financial support or care due to health issues or disabilities. This definition may vary slightly based on specific insurance policies. When navigating this process, the Premera Blue Cross Disabled Dependent Form will provide clear guidance on what qualifies someone as your dependent.

A disabled adult dependent is typically someone who is 18 years or older and relies on you for financial support due to a physical or mental disability. To be recognized as a disabled dependent, they must have a disability that limits their ability to perform daily activities. The Premera Blue Cross Disabled Dependent Form can help establish their status for insurance purposes.

When filling out the Premera Blue Cross Disabled Dependent Form, be clear and thorough in providing personal details, medical history, and specifics about the disability. Include any supporting documents that affirm the dependent’s condition. This clarity will help expedite the review process and ensure the right benefits are provided.

To qualify as a disabled dependent, an individual must be unable to live independently due to a health condition. The Premera Blue Cross Disabled Dependent Form will guide you in providing essential details that prove the person's disability. Reviewing specific eligibility criteria beforehand can enhance your application’s success rate.

A disabled dependent qualifies as someone who requires assistance due to a mental or physical condition that limits their capability to engage in daily activities. Completing the Premera Blue Cross Disabled Dependent Form will help in assessing their status accurately. It’s important to gather all necessary medical records and documentation for a smooth approval process.

In California, a disabled dependent is typically someone who cannot earn a living due to a physical or mental condition. The Premera Blue Cross Disabled Dependent Form requires documentation of this condition to validate the dependent's status. Qualifications may vary, so reviewing official guidelines or consulting an expert is advisable.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232