Get Ca Disabled Dependent Certification - San Bernardino County 2014-2025

The CA Disabled Dependent Certification form is essential for individuals seeking to certify a dependent child who is age 26 or older and has a disability. This guide will walk you through the process of filling out this form carefully and accurately online.

Follow the steps to complete the certification form effectively.

1. Begin by selecting the ‘Get Form’ button to access the Disabled Dependent Certification form and open it for editing.
2. Fill in your employee ID and record number at the top of the form. Ensure you include your email address.
3. Provide your last name, first name, and telephone number, along with your department name.
4. Indicate the name of your medical plan and dental plan. These details are crucial for the verification process.
5. For each dependent child age 26 or older that you are certifying, complete a separate form. Fill out the dependent's name and date of birth.
6. Specify the dependent's relationship to you, the employee.
7. Complete the provider certification section by noting the type of disability (permanent or temporary). If temporary, include the end date.
8. Enter the healthcare provider's name, address, license number, and telephone number. Ensure that the provider signs and dates the certification.
9. Sign the employee certification section, confirming that all information is accurate and that you understand the implications of providing incorrect information.
10. If applicable, fill out the payroll specialist area and ensure it is signed and dated.
11. After you have filled out the form completely, you can save your changes, download the document, print it, or share it as needed.

Complete your CA Disabled Dependent Certification online today to ensure your dependent receives the necessary coverage.