Bcbs Small Group Pediatric Dental Ehb Attestation Form Page 2
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3Small Group Pediatric Dental EHB Attestation Form
Plan Year
/
/
(MM/DD/YYYY)
Effective Date
/
/
(MM/DD/YYYY)
Please check one:
r ATTESTATION: I/We attest that ALL participants enrolled in our applicable Blue Cross and Blue Shield
medical plan(s) have coverage for Pediatric Dental EHBs through a policy issued by Blue Cross and
Blue Shield or another company.
r ATTESTATION: I/We attest that ALL participants enrolled in our applicable Blue Cross and Blue Shield
medical plan(s) do not have coverage for Pediatric Dental EHBs through a policy issued by Blue Cross
and Blue Shield or another company. Please add Low Child Only Dental Plan, the limited dental qualified
health plan (QHP), to all participants at an additional premium cost.
r ATTESTATION: I/We attest that ALL the participants LISTED IN THE TABLE on PAGE THREE are
enrolled in our applicable Blue Cross and Blue Shield medical plan(s) AND have coverage for Pediatric
Dental EHBs through a policy issued by Blue Cross and Blue Shield or another company.
Please add Low Child Only Dental Plan, to those participants not listed in the grid below who are
enrolled in our applicable Blue Cross and Blue Shield medical plan(s). Once those participants not listed
in the grid below are enrolled in Low Child Only Dental Plan, ALL participants enrolled in our applicable
Blue Cross and Blue Shield medical plan(s) will have coverage for Pediatric Dental EHBs through a
policy issued by Blue Cross and Blue Shield or another company. (Please use the table on page three
to list participant names.)
IMPORTANT: The Low Child Only Dental Plan, our limited dental qualified health plan (QHP), which
provides pediatric dental essential health benefits, will be added to your BCBSTX coverage at an
additional premium cost for any participants under age 19 (up to a maximum of three dependents)
unless you confirm that all your participants (enrolled in the applicable BCBSTX medical plan) have
pediatric dental EHB coverage through another policy.
Company Name
(Must include Group Number)
Date
Signature (e-signature)
Your Full Name (please print)
Title
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
728363.0914
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