Loading
Get Ca Anthem Blue Cross Disabled Dependent Certification
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the CA Anthem Blue Cross Disabled Dependent Certification online
Filling out the CA Anthem Blue Cross Disabled Dependent Certification is essential for certifying the status of a dependent with a disability. This guide provides clear instructions to help you complete the form accurately and efficiently.
Follow the steps to complete the certification form online.
- Click ‘Get Form’ button to obtain the form and open it in your preferred document editor.
- In the ‘Subscriber’s Name’ section, write the last name, first name, and middle initial of the subscriber responsible for the dependent.
- Enter the subscriber's identification number in the designated field, ensuring it is accurate for proper processing.
- Fill in the home address completely, including the number, street, city, state, and zip code to facilitate communication.
- Indicate the group name associated with the insurance policy in the appropriate section, followed by the group number.
- Provide the dependent's name, ensuring the correct spelling, then enter the dependent's birth date in the specified format.
- Select the dependent’s marital status by choosing the appropriate option (single, married, etc.).
- Answer whether the dependent qualifies to be claimed on your federal income tax return by selecting ‘Yes’ or ‘No’.
- Indicate if the dependent is employed by selecting ‘Yes’ or ‘No.’ If yes, provide the date of hire in the specified field.
- Record the number of hours the dependent works each week and describe their nature of duties in the respective fields.
- Sign the form in the designated area to certify that the information provided is correct and authorize the release of medical information.
- Date the form with the date you are completing it before forwarding it to the attending physician for their completion.
- Once the physician completes their section, return the form to Anthem Blue Cross using the provided address or the enclosed envelope.
Ensure your dependent's eligibility by completing the CA Anthem Blue Cross Disabled Dependent Certification online today.
Yes, Anthem Blue Cross is often used interchangeably with Anthem Blue Cross Blue Shield. They are part of the same network but may offer different insurance plans depending on your location. When seeking information about the CA Anthem Blue Cross Disabled Dependent Certification, it’s important to clarify which version of Anthem you are dealing with.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.