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Get Disabled Dependent Application Delta Dental Massachusetts Form

Print Form Customer Service MA Nat l Toll Free Corporate Office Fax Delta Dental of Massachusetts P. O. Box 9695 Boston MA 02114 www. deltadentalma.com 617. 886. 1234 800. 872. 0500 617. 886. 1000 800. 451. 1249 Disabled Dependent Application 1. SUBSCRIBER NAME FIRST LAST 2. SUBSCRIBER ID NUMBER 3. GROUP ID NUMBER 4. Print Form Customer Service MA Nat l Toll Free Corporate Office Fax Delta Dental of Massachusetts P. O. Box 9695 Boston MA 02114 www. deltadentalma*com 617. 886. 1234 800. 872. 0500 617. 886. 1000 800. 451. 1249 Disabled Dependent Application 1. SUBSCRIBER NAME FIRST LAST 2. SUBSCRIBER ID NUMBER 3. GROUP ID NUMBER 4. GROUP NAME 5. ADDRESS Number Street City State and Zip Code 6. NAME OF DEPENDENT CHILD 7. CHILD S DATE OF BIRTH Month Date Year 9. IS CHILD PERMANENTLY RESIDING IN YOUR HOUSEHOLD 10. IS CHILD DEPENDENT UPON YOU FOR SUPPORT YES Yes No 8. DATE CHILD S DISABILITY OCCURRED IF NO EXPLAIN 11. IF YES WHAT PART OF SUPPORT 12. IS CHILD LISTED AS A DEPENDENT IN YOUR LAST DO YOU CONTRIBUTE FEDERAL INCOME TAX STATEMENT NO 13. NAME AND ADDRESS OF PHYSICIAN WHO ATTENDED DEPENDENT CHILD. I have read the foregoing statements and answers and declare them to be true and complete to the best of my knowledge and belief* To the extent permitted by statute I here by authorize any physician or other person who has attended my above name dependent child o rwho may hereafter attend or examine such child to disclose any knowledge or information thereby acquired by him* Aphotostat of this authorization shall be valid as the original* SIGNATURE OF SUBSCRIBER DATE Return Form Directly To Delta Dental of Massachusetts TO BE COMPLETED BY ATTENDING PHYSICIAN 1. IS CHILD NOW INCAPABLE OF SELF-SUPPORT BECAUSE OF A DISABILITY 2. HAS SUCH DISABILITY EXISTED CONTINUOSLY 3. PROGNOSIS Estimate months or years SINCE BEFORE CHILD ATTAINED AGE 19 4. NATURE OF DISABILITY Please give as much detail as practicable SIGNATURE OF PHYSICIAN COP-128 4/12. Print Form Customer Service MA Nat l Toll Free Corporate Office Fax Delta Dental of Massachusetts P. O. Box 9695 Boston MA 02114 www. deltadentalma*com 617. 886. 1234 800. 872. 0500 617. 886. 1000 800. O. Box 9695 Boston MA 02114 www. deltadentalma*com 617. 886. 1234 800. 872. 0500 617. 886. 1000 800. 451. 1249 Disabled Dependent Application 1. SUBSCRIBER NAME FIRST LAST 2. SUBSCRIBER ID NUMBER 3. GROUP ID NUMBER 4. 451. 1249 Disabled Dependent Application 1. SUBSCRIBER NAME FIRST LAST 2. SUBSCRIBER ID NUMBER 3. GROUP ID NUMBER 4. GROUP NAME 5. ADDRESS Number Street City State and Zip Code 6. NAME OF DEPENDENT CHILD 7. CHILD S DATE OF BIRTH Month Date Year 9. GROUP NAME 5. ADDRESS Number Street City State and Zip Code 6. NAME OF DEPENDENT CHILD 7. CHILD S DATE OF BIRTH Month Date Year 9. IS CHILD PERMANENTLY RESIDING IN YOUR HOUSEHOLD 10. IS CHILD DEPENDENT UPON YOU FOR SUPPORT YES Yes No 8. IS CHILD PERMANENTLY RESIDING IN YOUR HOUSEHOLD 10. IS CHILD DEPENDENT UPON YOU FOR SUPPORT YES Yes No 8. DATE CHILD S DISABILITY OCCURRED IF NO EXPLAIN 11. IF YES WHAT PART OF SUPPORT 12. IS CHILD LISTED AS A DEPENDENT IN YOUR LAST DO YOU CONTRIBUTE FEDERAL INCOME TAX STATEMENT NO 13.

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