Get Nm Lanl Form 3028 - Los Alamos County 2021-2025

Filling out the NM LANL Form 3028, also known as the Declaration of Legal Ward as Eligible Dependent, is an important step for health insurance subscribers at Los Alamos County. This guide provides clear instructions to assist you in completing the form online accurately and efficiently.

Follow the steps to complete the NM LANL Form 3028 online.

1. Press the ‘Get Form’ button to access the form and open it in the designated editor.
2. Fill in your personal information as the health insurance subscriber, including your last name, first name, Z number, and social security number. Ensure all details are accurate to avoid processing delays.
3. Provide the details of the enrolled dependent by entering their last name, first name, Z number, and social security number. Remember that you need to complete a separate form for each enrolled dependent.
4. Read and understand the declaration statement carefully. This section outlines the eligibility criteria that must be met for the dependent to be recognized. Ensure you can attest to each point listed.
5. Sign and date the form, which certifies that the information provided is true and correct. This step is crucial, as any false information could lead to serious consequences.
6. Once all fields are completed, use the options provided to save your changes or download a copy. You may also print the form directly from the editor using the buttons labeled ‘SAVE’ and ‘PRINT’.
7. Submit your completed form to the LANL Benefits Office via fax at 505-665-2156 or by email at benefits@lanl.gov. Ensure submission is made by the required deadlines to affect payroll deductions properly.

Complete your NM LANL Form 3028 online today to ensure your health benefits are properly managed.