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Anthem disabled dependent certification form

Disabled dependent form 2025

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The document is a Disabled Dependent Certification form that requires completion by both the subscriber and the attending physician. It collects information about the subscriber, their dependent, and the dependent's disabling condition to determine eligibility for continued coverage under a health insurance plan. The form includes sections for personal details, employment status, and medical information related to the disability.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name in the Subscriber’s Name field, followed by your Identification Number. This ensures that your information is correctly linked to your account.
Fill in your Home Address, including the number, street, city, state, and zip code. Accurate address details are crucial for correspondence.
Provide the Group Name and Group Number associated with your insurance plan to facilitate processing.
Enter the Dependent’s Name and Birth Date. This identifies who you are certifying as a disabled dependent.
Indicate the Dependent’s Marital Status and whether they qualify to be claimed on your federal income tax return by selecting 'Yes' or 'No'.
If applicable, provide employment details of the dependent, including Date of Hire, hours worked per week, and a brief description of their duties.
Finally, certify that all information is correct by signing and dating the form before forwarding it to your physician for completion.

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Versions	Form popularity	Fillable & printable
2013	4.7 Satisfied (59 Votes)
2008	4 Satisfied (33 Votes)

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What qualifies someone as a disabled dependent?

Dependents: You may be able to claim your child as a dependent regardless of age if they are permanently and totally disabled. Permanently and totally disabled: y He or she cannot engage in any substantial gainful activity because of a physical or mental condition.

How do I add dependents to my VA disability?

The credit is non-refundable, meaning it can lower your tax bill to zero, but you will not receive any part of it back as a tax refund. Its worth up to $1,050 for one qualifying dependent, maxing out at $2,100 for two or more qualifying dependents.

What is a disabled dependent form?

The Disabled Dependent Certification form is used to determine if your adult dependent child meets the plans eligibility requirements for continued coverage after the age limit is docHubed.

What is the form for disabled dependents?

Form 10-IA is a medical certificate issued by a government medical authority for individuals with disabilities or their dependents. It is essential to claim tax deductions under sections 80DD and 80U of the Income Tax Act.

How to apply for disability for a dependent?

You can apply for benefits by calling our national toll-free service at 1-800-772-1213 (TTY 1-800-325-0778) or by visiting your local Social Security office. An appointment is not required, but if you call ahead and schedule one, it may reduce the time you spend waiting to apply.

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What qualifies as a disabled dependent?

The eligible dependent must have a qualifying diagnosis from a physician stating the dependent suffers from a disabling condition. The dependent must be unable to support himself/herself financially and must have at least six (6) months of creditable coverage as defined in the Evidence of Coverage booklet.