Disabled Dependent Application for State Health Plan (BCBSM) and Blue Care Network members. Disabled Dependent Application for State Health Plan (BCBSM) and Blue Care Network members 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section A: Subscriber Information. Fill in your name, contract number, birth date, marital status, sex, and primary residence details.
3. Proceed to Section B: Dependent Information. Enter your incapacitated dependent's first and last name, relationship, social security number, sex, birth date, date condition developed, and diagnosis.
4. In Section C: Medicare Information, indicate if the dependent is entitled to Medicare due to their condition by selecting 'Yes' or 'No'.
5. Complete Section D: Other Insurance if applicable. Provide details about any other health insurance coverage your dependent may have.
6. Fill out Section E: Additional Information as needed.
7. In Section F: Verification, confirm that you are requesting coverage for your dependent and sign the form.
8. Ensure that a physician completes Section G: Dependent’s Attending Physician Certification with all required medical information.
9. Finally, review all sections for accuracy before printing the completed form and mailing it to the specified address.

Start using our platform today to easily complete your application online for free!