Dependent certification form 2025

1. Click ‘Get Form’ to open the dependent certification form in the editor.
2. Begin by entering your Member Name and Individual Plan # at the top of the form. This information is essential for identifying your account.
3. Fill in the Dependent Name and Date of Birth. Ensure accuracy as this data is crucial for eligibility verification.
4. Complete the Member Address and Member ID # fields to provide your contact details.
5. In the Student Certification section, answer whether your dependent is a full-time student. If yes, provide the name, address, telephone number of their school, expected graduation date, and Student ID#.
6. For Adult Dependent Certification, indicate if your dependent is unmarried, a full-time student, and claimed on your Federal Tax Forms by selecting YES or NO.
7. In the Disability Certification section, answer if your dependent is incapable of self-support due to a disability. Provide details about the nature of the disability and prognosis.
8. Finally, sign and date the form at the bottom to certify that all information provided is correct.

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