Form 03-B0096 - Extended Student Coverage Due To Medical Leave - Bluecross Blueshield Of Northeastern Pennsylvania

EXTENDED STUDENT COVERAGE

DUE TO MEDICAL LEAVE

Subscriber Information

Please print or type.

NOTE: Any fee for completion of this form is your responsibility.

Last name: ! Mr. ! Mrs. ! Miss ! Ms.

First name:

Middle name:

E-mail:

Street address:

City:

State: ZIP:

County:

Country:

ID number:

Group number:

Name of employer:

I request consideration of coverage under my membership agreement for the dependent named below, who is taking a medical leave of absence.

Dependent Information

Name of dependent: (Last name, first name, middle initial)

Social Security Number:

Date of birth:

(mm/dd/yyyy)

____ ____ ____

____ ____

____ ____ ____ ____

____ / ____ / ________

Relationship to subscriber:

Where is the dependent living now?

Dependent marital status:

Dependent employment status:

Sex:

Dependent student status:

School enrollment date

:

____ / _____ / ________

(mm/dd/yyyy)

! Single

! Divorced

! Separated

! Full-time

! Male

! Full-time

Expected date of graduation

:

____ / _____ / ________

(mm/dd/yyyy)

! Married/date of marriage:

! Part-time

! Female

! Part-time

Name of school:

____ / ____ / ____

________________________________________

The above information is correct to the best of my knowledge and I authorize release of any information requested with respect to this certification. I hereby authorize any insurance company,

prepayment organization, employer, hospital, physician or other organization providing medical services to the dependent noted above to release any information or medical records with respect to the

dependent noted above to Blue Cross of Northeastern Pennsylvania and any of its affiliates or designees, as it relates to any program providing benefits or services. Any person who knowingly and with

intent to defraud any insurance company or other 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 subjects such person to criminal and civil penalties.

Subscriber’s signature ____________________________________________________________________________________________________________

Date ________________________________

Group administrator’s signature ____________________________________________________________________________________________________

Date ________________________________

To Be Completed by Attending Physician

Physician’s name: (Please print or type)

Street address:

City:

State:

ZIP:

Date of treatment:

Student is unable to attend school due to medical reasons:

Required to extend student’s medical coverage

(mm/dd/yyyy)

From

____ / ____ / _____

to

____ / ____ / _____

as per Michelle’s Law (HR 2851).

Beginning

____ / ____ / _____

and ending

____ / ____ / _____

Physician’s signature ____________________________________________________________________________________________________________

Date ________________________________

For Blue Cross

Use Only

®

! Certified from

to

____ / ____ / _____

____ / ____ / _____

Please complete the entire form. This form will not be processed without the required signatures.

®

®

Blue Cross of Northeastern Pennsylvania administers health care plans offered by Blue Cross of Northeastern Pennsylvania, Highmark Blue Shield, First Priority Health

and First Life Insurance Company

.

03-B0096 9/09