Impaired Dependent Certification (Page 2 of 2) in pdf

Impaired Dependent Certification Page 2

Physician Name:

Type or Print

Physician’s Signature:

Physician’s Degree:

Physician’s Mailing Address:

Telephone Number:

Part III

(To be completed by the School Benefits Administrator)

School Name: ______________________________________________________________________________

School Address: _____________________________________________________________________________

__________________________________________________________________________________________

Contact Person (Employee’s Benefit Specialist):

Phone Number:

Date:

Part IV

(To be completed by NMPSIA Eligibility Administrator)

Effective date of Employee’s Insurance:

Effective date of dependent coverage:

 Yes

 No

Has Employee’s dependent coverage been continuously in effect up to the present date?

Please explain:

__________________________________________________________________________________________

NMPSIA Eligibility Representative:

Phone Number: 1-800-233-3164

Date:

Comments:

__________________________________________________________________________________________

Eligibility Representative Signature:

Date:

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.

2/13

pubsformslarge_group mpsia_depencert.doc

Impaired Dependent Certification Page 2