Verification Of Eligibility For Certain Dependent Children Form

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Contract Number: _______________ Group/Division Number: _____________________ SA Clerk Code: _____________________

VERIFICATION OF ELIGIBILITY FOR CERTAIN DEPENDENT CHILDREN

The limiting age and satisfaction requirements for a dependent child is set forth in the contract issued to your employer by Blue Cross & Blue Shield

of Florida, Inc. or Health Options, Inc. (BCBSF/HOI). BCBSF/HOI may request documentation to ensure that a child meets and continues to

meet such requirements. This eligibility provision does not modify any other eligibility requirements. (Please refer to your Certificate of

Coverage, Benefit Booklet, or Member Handbook, including any Endorsements, for more information.)

CRITERIA FOR DEPENDENTS AGES 19-25

A dependent child (age 19-25) may be allowed to remain covered provided the child meets the following requirements:

The child is dependent upon the certificate holder for support; AND

The child is living in the household of the certificate holder, and/or

The child is a full time or part-time student (you must refer to your Certificate of Coverage, Benefit Booklet, or Member Handbook

including any Endorsements, for group specific student status criteria)

Based upon the above dependent criteria, please place a check mark in column 5, next to the dependent child (ren) that NO LONGER meet the

criteria. . (Please refer to your Certificate of Coverage, Benefit Booklet, or Member Handbook, including any Endorsements for more information.)

Please do not use this form to add dependents into your plan. For additions you must contact your Group Administrator.

Relation to me:

Dependent's Name

Social Security Number

Date of Birth

Dependent does not meet

Indicate if son or

eligibility criteria for

daughter. If other, please

ages 19-25. Please

explain.

terminate effective

12/31/2008.

THIS SECTION MUST BE COMPLETED BY THE EMPLOYEE

I represent that the statements on this form are true and complete. I understand that the dependent/dependents that no longer

meet all the criteria specified in the group contract as described in my Certificate of Coverage, Endorsements, or Member

Handbook, will terminate coverage/membership.

Employee Signature_________________________________________________________________________________________

Contract Number or Social Security Number: ____________________________________________________Date_______________

This form should only be returned if the dependent child (ren) does not meet eligibility and is being terminated.

INCAPACITATED OR HANDICAPPED DEPENDENTS: Please attach a statement from the dependent's physician certifying that the dependent is

incapable of self-sustaining employment by reason of mental retardation or physical handicap, and is chiefly dependent upon the certificate holder for

support and maintenance. (Please refer to your Certificate of Coverage,Benefit Booklet or Member Handbook for more information.)

IMPORTANT NOTICE FOR COBRA/FHICCA CONTINUANTS: If you and your dependents are currently continuing health care coverage

through COBRA/FHICCA, you must adhere to the guidelines concerning enrollment verification required by the COBRA/FHICCA

administrator for your group health plan. Please contact your COBRA/FHICCA Administrator for details

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