Get Declaration Of Age

Declaration of disability for over age dependent child Use Full-time Student Certification form if your over age dependent is a full-time student and on a medical leave of absence. Enrolled dependent children who would normally lose their eligibility under this plan solely because of age but who are disabled by reason of a physically or mentally disabling injury illness or condition may have their eligibility extended by written application within 31 days of the date the dependent child reaches the age eligibility would otherwise cease. To qualify for this extension the disabled dependent child must be incapable of self-sustaining employment and be chiefly dependent upon the subscriber for support and maintenance. This medical certification of disability must accompany the application unless you and the dependent are already enrolled in a Blue Shield plan* A recertification of disability may be required within two years after the initial medical certification and annually thereafter except in cases of long-term disability. Subscriber s name Group number Member number Dependent child s name I the undersigned physician certify that dependent name is incapable of self-sustaining employment because of Prognosis Estimated date of ability for self-sustaining employment Physician Date Name Date of birth is an unmarried child including any stepchild legally adopted child or foster child is chiefly employment by reason of physical or mental handicap* Parent or guardian If the parent or guardian and dependent have not been covered by a Blue Shield health plan prior to the age that dependent eligibility ceases evidence of current prior dependent coverage will be required* For these situations the HIPAA certificate from the prior carrier will be required* blueshieldca*com An Independent Licensee of the Blue Shield Association diagnosis of disabled over age dependent child C3674 1/09. Enrolled dependent children who would normally lose their eligibility under this plan solely because of age but who are disabled by reason of a physically or mentally disabling injury illness or condition may have their eligibility extended by written application within 31 days of the date the dependent child reaches the age eligibility would otherwise cease. To qualify for this extension the disabled dependent child must be incapable of self-sustaining employment and be chiefly dependent upon the subscriber for support and maintenance. To qualify for this extension the disabled dependent child must be incapable of self-sustaining employment and be chiefly dependent upon the subscriber for support and maintenance. This medical certification of disability must accompany the application unless you and the dependent are already enrolled in a Blue Shield plan* A recertification of disability may be required within two years after the initial medical certification and annually thereafter except in cases of long-term disability. This medical certification of disability must accompany the application unless you and the dependent are already enrolled in a Blue Shield plan* A recertification of disability may be required within two years after the initial medical certification and annually thereafter except in cases of long-term disability. Subscriber s name Group number Member number Dependent child s name I the undersigned physician certify that dependent name is incapable of self-sustaining employment because of Prognosis Estimated date of ability for self-sustaining employment Physician Date Name Date of birth is an unmarried child including any stepchild legally adopted child or foster child is chiefly employment by reason of physical or mental handicap* Parent or guardian If the parent or guardian and dependent have not been covered by a Blue Shield health plan prior to the age that dependent eligibility ceases evidence of current prior dependent coverage will be required* For these situations the HIPAA certificate from the prior carrier will be required* blueshieldca*com An Independent Licensee of the Blue Shield Association diagnosis of disabled over age dependent child C3674 1/09.