Get Disabled Dependent Application Delta Dental Massachusetts Form

Filling out the Disabled Dependent Application Delta Dental Massachusetts Form online ensures a streamlined process for obtaining coverage for your dependent. This guide provides detailed, step-by-step instructions for each section of the form, making it easier for you to provide accurate information.

Follow the steps to complete the application accurately.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin filling out the form by entering your full name as the subscriber, including your first and last names.
3. Input your subscriber ID number in the specified field for identification purposes.
4. Provide your group ID number, which can usually be found on your insurance card.
5. Fill in the group name associated with your insurance plan.
6. Enter your complete address, including number, street name, city, state, and zip code.
7. Clearly state the name of the dependent child for whom you are applying.
8. Indicate the child’s date of birth by filling in the month, date, and year.
9. Answer whether the child is permanently residing in your household, confirming their living situation.
10. Provide information on whether the child is dependent upon you for support, selecting 'Yes' or 'No'.
11. If you answered 'Yes' to support, specify what part of support you contribute.
12. Indicate if the child is listed as a dependent in your last federal income tax statement.
13. Provide the name and address of the physician who attended to your dependent child.
14. Sign and date the form, confirming that all information provided is true and complete to your knowledge.
15. Return the completed form directly to Delta Dental of Massachusetts at the address provided on the form.

Take the first step towards securing coverage for your dependent by completing the application online.