01. Edit your anthem disabled dependent certification form online
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Disabled dependent form 2026
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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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disabled dependent certification form pdf
The patient requests you to complete this Medical Report form. It will assist CalPERS in processing their claim for health/dental insurance as a disabledRead more
You can use this form if one of your dependents will be too old to stay on your plan, but you want to request to keep them covered.