Public law 110381, also known as Michelles Law, allows dependent college students insured under their - bcbstx 2026

1. Click ‘Get Form’ to open it in the editor.
2. In Section 1, complete all fields including Group No., Subscriber Identification No., Subscriber Name, Dependent Student Name, and Dependent Student Date of Birth. Ensure accuracy as this information is crucial for certification.
3. Sign and date the form in Section 1 to certify that the provided information is correct.
4. Move to Section 2, where your attending physician must complete all fields. They will confirm if the student is suffering from a serious illness or injury by selecting 'Yes' or 'No'.
5. If applicable, provide an explanation of the medical condition and indicate whether the leave of absence is medically necessary.
6. Fill in the effective date and end date for the medical leave. The attending physician must sign and include their NPI Number along with the date.
7. Review all entries for completeness before submitting. All fields on this form MUST be completed.

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