Emblemhealth dependent student certification form: Fill out & sign online

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Click ‘Get Form’ to open the dependent student certification form in our editor.
Begin by filling out Section One, which includes your member information. Enter your Tax ID, name, address, and email in the designated fields.
Next, provide your dependent's information. Fill in their name and date of birth accurately.
Indicate the name of the school your dependent is attending and their school phone number.
Certify your dependent's eligibility by answering the questions regarding age, marital status, and full-time enrollment. Circle 'Yes' or 'No' as applicable.
Select the semester (Fall or Spring) and enter the year before signing and dating the form.
In Section Two, ensure that an authorized person from the registrar’s office completes their part regarding full-time enrollment and accreditation status.
Finally, mail, fax, or email the validated form to the SBA Health & Welfare Office as instructed at the bottom of the document.

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