Get State Health Plan Disabled Dependent Application - Michigan

Completing the State Health Plan Disabled Dependent Application is a critical process for ensuring that your dependent receives necessary health coverage. This guide provides clear, step-by-step instructions on how to fill out the form online effectively.

Follow the steps to complete your application online successfully.

1. Press the ‘Get Form’ button to access the application and open it in your chosen online editor.
2. In Section A, provide the subscriber information, including your name, contract number, marital status, date of birth, sex, primary residence, and telephone numbers. Ensure all required fields are filled accurately.
3. In Section B, enter the details for your incapacitated dependent. Include their first and last name, relationship to you, social security number, sex, date of birth, date the condition developed, and the diagnosis. Attach supportive documentation from a physician that verifies the dependent's condition.
4. In Section C, indicate whether your dependent is entitled to Medicare by selecting 'Yes' or 'No'.
5. In Section D, if your dependent has other health insurance, provide the necessary details, including the name of the insured, insurance company information, and policy details.
6. Section E may require additional information relevant to your dependent's health coverage.
7. In Section F, read the verification statement carefully, and certify that the information provided is accurate by entering your signature and the date signed.
8. After completing the form, save any changes, and prepare to download, print, or share the completed application as needed.

Complete your application online to ensure your dependent receives the necessary health coverage.