Guardian dependent 2026

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

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