Get Adult Dependent Coordination Of Benefits Form - State Of Delaware - Ben Omb Delaware

The Adult Dependent Coordination Of Benefits Form is essential for ensuring that your adult dependent receives the appropriate health care coverage under the State of Delaware plan. This guide provides step-by-step instructions on how to fill out the form effectively.

Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in your full name, ensuring to include your last, first, and middle initial. Move on to provide your home phone number with the area code.
3. Enter your Social Security number in the designated field.
4. Indicate whether this is the first form or an updated form for your adult dependent by selecting the appropriate option.
5. Provide your adult dependent’s full name, including last, first, and middle initial, along with their Social Security number.
6. Mark your dependent’s gender by checking the appropriate box for Male or Female.
7. Fill in your dependent’s birth date in the specified format.
8. Indicate your relationship to the adult dependent by selecting from the employer information section.
9. If applicable, include the name and address of the employer of your adult dependent.
10. Answer whether the employer offers health care insurance to employees with a ‘Yes’ or ‘No’ selection.
11. State the name of your adult dependent’s health care insurance carrier.
12. Provide the employer's phone number, ensuring to include the area code.
13. Specify if your adult dependent is enrolled in health care insurance through their employer by selecting ‘Yes’ or ‘No’.
14. If not enrolled, state the percentage of the premium that your adult dependent would have to pay for the lowest benefit plan.
15. Indicate whether the plan is a High Deductible Plan with a Health Savings Account.
16. Provide the policy number and the annual plan renewal date for the employer.
17. Indicate the effective date in the specified format.
18. Specify whether the employer’s medical plan covers prescription drugs with a ‘Yes’ or ‘No’ selection.
19. If completing the form due to the adult dependent’s loss of coverage, enter the termination date of that coverage.
20. Review the authorization section, ensuring you understand the implications of submitting the form.
21. Sign and date the form at the bottom to certify that the information provided is correct.
22. After completing the form, save your changes, and you can opt to download, print, or share it as required.

Complete your Adult Dependent Coordination Of Benefits Form online today to ensure your dependent's health coverage is managed efficiently.