Fillable Disability Status Request Form - Emblem Health printable pdf download

DISABILITY STATUS REQUEST FORM

Return form and requested documents to: PO Box 2820, New York, NY 10016-2820

BY COMPLETING THIS FORM THE SUBSCRIBER IS REQUESTING COVERAGE BEYOND THE NORMAL LIMITING AGE FOR AN

ADULT DEPENDENT WHO IS INCAPABLE OF SELF-SUSTAINING EMPLOYMENT. Please note that we will not be able to continue coverage

for your dependent unless we receive, review and approve your paperwork within 31 days of your dependent reaching the limiting age.

Select Plan:

EmblemHealth

GHI

GHI HMO

HIP

VYTRA

SUBSCRIBER INFORMATION

Subscriber ID Number

Subscriber Name

Phone Number

Address of Subscriber (Number and Street)

Apt

City

State

ZIP Code

Email Address

“Go Paperless” and Save Trees!

By electing “Go Paperless,” you will receive claim statements and some other EmblemHealth letters by e-mail instead of paper mail. You will be able to view

your Explanation of Benefits (EOBs) under the Claims section of the EmblemHealth Web site when you sign on. Your enrollment in the “Go Paperless” option

will continue as long as your account remains active or until you choose to discontinue this option.

DEPENDENT INFORMATION

Dependent ID Number

Dependent Name

Dependent Date of Birth

Sex

Male

Female

Dependent Relationship to Subscriber

Dependent Marital Status

Son

Daughter

Other _________________________________

Single

Widowed

Married

Divorced

The dependent listed above is the unmarried child, stepchild or adoptive child of my spouse or myself and is at least the age of 26.

YES

The dependent listed above resides with me or my spouse.

YES

Has the dependent listed above ever been institutionalized?

YES

If Yes, give name and address of institution ____________________________________________________________________

_______________________________________________________________________________________________________

Period of Confinement (dates) ______________________________________

Was the dependent ever employed for wages?

YES

Presently working/last worked at _________________________________________________________ Hours per week _______

Is the dependent eligible for care under Medicare?

YES

Has the dependent been found eligible as disabled by supplemental security income (SSI) or social security disability insurance (SSDI)?

YES

(If yes, documentation is required to evaluate disabled dependent coverage. Example: Notice of award letter)

IMPORTANT: This form will not be processed without a physician’s summary of the dependent’s condition (see

reverse for details). Failure to submit the requested documents may result in a delay, denial or termination of

coverage for the above-named dependent.

I certify that I have carefully and fully read the important information on the next page of this form. I also certify that the statements and answers given are

complete and correct to the best of my knowledge and belief. No information required to be given, either expressly or by implication, has been knowingly

withheld. I have provided supportive documentation on my dependent’s disability as requested above and I am aware that without proper documentation

coverage may be denied. I am also aware that additional information may be required to make a determination of coverage and that presenting this

documentation does not imply automatic coverage.

I agree to promptly advise EmblemHealth within 30 days of any change that affects the young adult’s eligibility. I understand that any person who knowingly

and with intent to defraud any insurance company or person files an application for insurance or statement of claim containing any materially false

information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a

crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Subscriber Signature ________________________________________________________________

Date ________________________

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth

Services Company, LLC provides administrative services to the EmblemHealth companies.

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Vytra is a division of HIP Health Plan of New York (HIP), an EmblemHealth company.