Dependent Certification Form - For Massachusetts Based Employer Groups printable pdf download

DEPENDENT CERTIFICATION FORM

FOR MASSACHUSETTS BASED

EMPLOYER GROUPS

Subscriber’s name: ____________________________________________________________________________

Subscriber’s Tufts Health Plan ID number: ___________-_________-___________

I certify that:

__________________________________________________

_______/_______/___________

(Name of dependent)

(Date of Birth)

Please check one:

Ì Is currently a FULL-TIME STUDENT

At:

__________________________________________________ (Name of accredited educational institution)

__________________________________________________ (Institution address)

__________________________________________________ (Institution City, State and Zip)

__________________________________________________ (Registrar’s telephone number)

Expected date of graduation from college: ______/______ (if graduating this year, please complete the statements below)

Ì Is NOT A FULL-TIME STUDENT

If not a full-time student, please complete the statements below so that Tufts Health Plan can determine the

coverage end date applicable under Massachusetts and/or Federal Law.

____The above named person last qualified as a dependent as defined under the Internal Revenue Service (IRS) code

during calendar year*_____________

____The dependent has a medical condition that resulted in a medically necessary leave of absence from, or change in

enrollment at a post secondary educational institution.** This leave started on ___________________________

(A completed physician certification form must be submitted. This form can be found at )

I further certify that the information I have provided above is true and correct, and that I understand that:

• Tufts Health Plan may contact the educational institution and take any other steps it feels necessary to

verify the accuracy of the information I have provided.

• If there is any misrepresentation in the information I have provided, Tufts Health Plan may end my depen-

dent’s coverage as well as my entire family’s coverage, and may seek any other legal remedies available.

Subscriber’s signature: _____________________________________________ Date: ____________________

(Must be Employee’s signature)

Please return this completed and signed form to:

Tufts Health Plan

Commercial Enrollment and Premium Billing Department

P. O. Box 9186, Watertown, MA 02471-9186

Fax: 617-923-5898

continued on reverse

Dependent Certification Form - For Massachusetts Based Employer Groups