Get Tx Blue Cross Blue Shield Dependent Student Medical Leave Certification Form 2011

This guide provides clear, step-by-step instructions for completing the TX Blue Cross Blue Shield Dependent Student Medical Leave Certification Form online. By following these directions, users can ensure a smooth submission process to maintain coverage for dependent students during a medical leave of absence.

Follow the steps to complete the form online

1. Click the ‘Get Form’ button to obtain the form and display it in your document editor.
2. In Section 1, complete all required fields as the Subscriber: enter the Group Number, Subscriber Identification Number, and Subscriber Name. Enter the Dependent Student Name and Date of Birth. Confirm the accuracy of the information provided, then sign and date the Member Signature field.
3. In Section 2, the Attending Physician must provide their information. Answer the question regarding whether the student is suffering from a serious illness or injury by selecting 'Yes' or 'No.' If 'No', provide an explanation of the medical condition in the space provided, and attach additional information if needed.
4. Indicate if the leave of absence or other enrollment changes are medically necessary by selecting 'Yes' or 'No.' If 'Yes', fill in the effective date of the medical leave and the end date.
5. The Attending Physician must then sign and provide their National Provider Identifier (NPI) Number, along with the date of completion.
6. Ensure all fields are completed before finalizing the form. Review the entries for accuracy.
7. Once completed, save the changes, and download, print, or share the form as appropriate.

Complete your forms online to ensure your dependent's coverage.