Get Request For Continuance Of Enrollment For Disabled Dependent

Completing the Request For Continuance Of Enrollment For Disabled Dependent online can be a straightforward process with the right guidance. This guide will walk you through each section of the form, ensuring that you provide all necessary information accurately and efficiently.

Follow the steps to successfully fill out your form.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. In Part I, begin by entering your name as the subscriber in the designated box. This information identifies you as the person making the request.
3. Next, provide your telephone number, ensuring that it is accurate and includes the area code.
4. Fill in your address, including street, city, state, and zip code. This information is necessary for correspondence regarding the application.
5. Enter the dependent’s name, ensuring that the spelling is correct as it appears on their identification.
6. Indicate your relationship to the dependent, selecting the appropriate option from the choices provided.
7. Provide the dependent’s birth date, ensuring you use the correct format for clarity.
8. Record the date of onset of the dependent's disability or condition, as this is crucial for eligibility determinations.
9. List the name of the present insurance carrier for the dependent and their corresponding ID or policy number, along with the group number.
10. Indicate the coverage start and end dates to confirm the timeline of the dependent’s insurance.
11. Inquire about prior insurance carriers and document their details if applicable, including coverage duration.
12. Clearly state your reasons for applying for continuation of benefits in the space provided; this aids the review process.
13. Answer the questions regarding the dependent's ability to perform activities of daily living, their capacity for independent travel, and any employment status.
14. Finally, complete Part II by providing the dependent’s attending physician with this section for their input, ensuring they sign and include necessary details.
15. Review all entries for accuracy and completeness before submission. Make necessary corrections in the online editor.
16. Once all information is confirmed, save changes to the form, and download or print a copy for your records and submission.

Start the process of completing your Request For Continuance Of Enrollment For Disabled Dependent online today.