Get Mi Bcbs Wf 10676 2021-2025

Completing the MI BCBS WF 10676 form is essential for State of Michigan employees and retirees who wish to continue health coverage for their disabled dependents. This guide will provide you with clear and concise instructions on how to fill out the form effectively.

Follow the steps to complete your application effortlessly.

1. Click 'Get Form' button to obtain the form and open it in the online editor.
2. Enter your subscriber information in Section A. Provide your name, contract number, marital status, birth date, sex, primary residence details, and contact numbers.
3. In Section B, provide details about your incapacitated dependent. This includes their first and last name, relationship to you, social security number, sex, birth date, and the diagnosis.
4. Complete Section C regarding Medicare information. Indicate whether the dependent is entitled to Medicare due to their condition (Yes/No).
5. In Section D, address any other insurance. If your dependent is covered by additional health insurance, list the insured's name, insurance company details, and policy information.
6. Fill out Section E for any additional information relevant to your application.
7. In Section F, verify your request by acknowledging the requirements for dependent coverage and providing your signature and date.
8. Ensure Section G is completed by your dependent’s attending physician, including their certification, diagnosis, and treatment plan.
9. Review all sections carefully to ensure accuracy before submitting. Save changes, download, print, or share the completed form as needed.

Submit your completed application online today to ensure your dependent continues to receive the necessary health coverage.