Get Return Form And Requested Documents To: Po Box 2820, New York, Ny 10016-2820

Completing the Return Form And Requested Documents is a vital step in ensuring continued coverage for your dependent beyond the normal limiting age. This guide will provide you with clear, step-by-step instructions to help you successfully fill out the form online.

Follow the steps to complete the form effortlessly.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Fill in the subscriber information. Provide your Subscriber ID Number, full name, address (including city, state, and ZIP code), social security number, apartment number, and phone number. An email address is also required if you choose to go paperless.
3. Complete the dependent information section. Enter the Dependent ID Number, name, date of birth, and social security number. Indicate the dependent's relationship to you and select their marital status.
4. Answer the questions regarding your dependent's capacity for self-sustaining employment, residency, and eligibility for Medicare. If applicable, provide details about any institutionalization.
5. Indicate if your dependent has been found eligible for disability benefits such as supplemental security income (SSI) or social security disability insurance (SSDI). If yes, include supporting documentation.
6. Ensure to include a physician's summary of your dependent’s condition as specified in the instructions. This summary must be on official stationery and provide detailed information as listed.
7. Read the important information at the bottom of the form. Certify that you have accurately filled out the form by signing and dating it.
8. After reviewing all the information, save your completed form. You may then download, print, or share the document as needed.

Complete your documents online today to ensure your dependent's coverage remains uninterrupted.