Form ENR-187 "Disabled Child Application - Highmark Blue Cross Blue Shield" - Delaware

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Download Form ENR-187 "Disabled Child Application - Highmark Blue Cross Blue Shield" - Delaware

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DISABLED CHILD APPLICATION
INSTRUCTIONS
1. Parent should complete the first page of the form, enter information on the first line on page two and then forward to the doctor who treats your
child for this disability to complete the second page. Please mail or fax the completed form as instructed on page two.
2. Incomplete applications will be returned.
3. Please read the eligibility requirements below for a disabled child. Highmark Blue Cross Blue Shield Delaware (Highmark DE) as final approval on
all applications.
ELIGIBILITY REQUIREMENTS
A disabled child can be covered after the maximum dependent child age allowed on the policy if all the following requirements are met:
a) Child is unmarried
d) Child has a disability that:
occurred prior to reaching the maximum dependent child age; and
b) Child is covered as a dependent by a parent as of the date the
is expected to last more than 12 months or is terminal in nature; and
child reaches the maximum dependent child age
is so severe the child is incapable of self-support
c) Child receives 50% or more of support by his/her parent
e) Child is not eligible for coverage under:
Another health plan or
Medicare or Medicaid (unless federal or state law requires otherwise)
SECTION ONE  CUSTOMER INFORMATION
Customer’s Last Name (last name of parent)
First Name
Middle Initial
Telephone Number (include area code)
Customer’s Address (street, city, state, zip code)
Identification Number
Account Number or Employer Name
Do you and/or another parent provide more than
50% support for this dependent?
n n
n n
Yes
No
SECTION TWO  DEPENDENT INFORMATION
Dependent’s Last Name
First Name
Middle Initial
Marital Status
n n
n n
Single
Married
Dependent’s Birth Date
Dependent’s Relationship To Customer
Dependent’s Address (If different than above)
n n
n n
n n
Other (explain):
/
/
Son
Daughter
Is dependent employed?
If Yes, Name of Employer
Hours Worked
Rate of Pay
Type of Work Performed
n n
n n
Yes
No
_______ Per week
$________ Per hour
Is this dependent eligible for coverage under another
If Yes, Please explain. If Plan is with Highmark DE, provide ID Number.
n n
n n
health plan?
Yes
No
n n
n n
Is this dependent eligible for Medicare?
Yes
No
If Yes, provide Medicare Claim Number and Part A and Part B Effective Date.
n n
n n
Is this dependent eligible for Medicaid?
Yes
No
If Yes, provide Medicaid Number and Effective Date.
n n
n n
Has child been covered by parent continuously prior to (and after if applicable) reaching the maximum dependent child age?
Yes
No
If yes, and carrier was not Highmark DE, please provide HIPAA certificates of coverage to show child was continuously insured.
SECTION THREE  TERMS AND SIGNATURE
I REQUEST COVERAGE FOR THE DEPENDENT CHILD NAMED ABOVE WHO IS DISABLED.
I understand and agree that:
1. Rights to service are subject to acceptance of this application and to the terms and conditions specified in the present contract and any future
contract between my employer, association and Highmark Blue Cross Blue Shield Delaware.
2. I certify that all representations and information supplied by me are true. My coverage shall be void if any part of this application is false or
incomplete.
3. I authorize any hospital, physician, professional review organization and any and all other providers of service to disclose and furnish to Highmark
Blue Cross Blue Shield Delaware and/or its agents any and all records relating to the disabled child named in this application for whom services or
benefits have been sought or to whom services or benefits have been provided, including a complete diagnosis and medical information.
I HAVE READ AND DO AGREE TO THE ABOVE TERMS
Date
Signature of Customer: X
/
/
Page 1 of 2
ENR-187 (9-12)
DISABLED CHILD APPLICATION
INSTRUCTIONS
1. Parent should complete the first page of the form, enter information on the first line on page two and then forward to the doctor who treats your
child for this disability to complete the second page. Please mail or fax the completed form as instructed on page two.
2. Incomplete applications will be returned.
3. Please read the eligibility requirements below for a disabled child. Highmark Blue Cross Blue Shield Delaware (Highmark DE) as final approval on
all applications.
ELIGIBILITY REQUIREMENTS
A disabled child can be covered after the maximum dependent child age allowed on the policy if all the following requirements are met:
a) Child is unmarried
d) Child has a disability that:
occurred prior to reaching the maximum dependent child age; and
b) Child is covered as a dependent by a parent as of the date the
is expected to last more than 12 months or is terminal in nature; and
child reaches the maximum dependent child age
is so severe the child is incapable of self-support
c) Child receives 50% or more of support by his/her parent
e) Child is not eligible for coverage under:
Another health plan or
Medicare or Medicaid (unless federal or state law requires otherwise)
SECTION ONE  CUSTOMER INFORMATION
Customer’s Last Name (last name of parent)
First Name
Middle Initial
Telephone Number (include area code)
Customer’s Address (street, city, state, zip code)
Identification Number
Account Number or Employer Name
Do you and/or another parent provide more than
50% support for this dependent?
n n
n n
Yes
No
SECTION TWO  DEPENDENT INFORMATION
Dependent’s Last Name
First Name
Middle Initial
Marital Status
n n
n n
Single
Married
Dependent’s Birth Date
Dependent’s Relationship To Customer
Dependent’s Address (If different than above)
n n
n n
n n
Other (explain):
/
/
Son
Daughter
Is dependent employed?
If Yes, Name of Employer
Hours Worked
Rate of Pay
Type of Work Performed
n n
n n
Yes
No
_______ Per week
$________ Per hour
Is this dependent eligible for coverage under another
If Yes, Please explain. If Plan is with Highmark DE, provide ID Number.
n n
n n
health plan?
Yes
No
n n
n n
Is this dependent eligible for Medicare?
Yes
No
If Yes, provide Medicare Claim Number and Part A and Part B Effective Date.
n n
n n
Is this dependent eligible for Medicaid?
Yes
No
If Yes, provide Medicaid Number and Effective Date.
n n
n n
Has child been covered by parent continuously prior to (and after if applicable) reaching the maximum dependent child age?
Yes
No
If yes, and carrier was not Highmark DE, please provide HIPAA certificates of coverage to show child was continuously insured.
SECTION THREE  TERMS AND SIGNATURE
I REQUEST COVERAGE FOR THE DEPENDENT CHILD NAMED ABOVE WHO IS DISABLED.
I understand and agree that:
1. Rights to service are subject to acceptance of this application and to the terms and conditions specified in the present contract and any future
contract between my employer, association and Highmark Blue Cross Blue Shield Delaware.
2. I certify that all representations and information supplied by me are true. My coverage shall be void if any part of this application is false or
incomplete.
3. I authorize any hospital, physician, professional review organization and any and all other providers of service to disclose and furnish to Highmark
Blue Cross Blue Shield Delaware and/or its agents any and all records relating to the disabled child named in this application for whom services or
benefits have been sought or to whom services or benefits have been provided, including a complete diagnosis and medical information.
I HAVE READ AND DO AGREE TO THE ABOVE TERMS
Date
Signature of Customer: X
/
/
Page 1 of 2
ENR-187 (9-12)
IMPORTANT!
PLEASE HAVE PHYSICIAN COMPLETE THIS SIDE OF THIS APPLICATION.
DISABLED CHILD APPLICATION
Dependent’s Last Name
First Name
Middle Initial
Dependent’s Birth Date
/
/
TO BE COMPLETED BY THE ATTENDING PHYSICIAN
Physician’s Name
Physician’s Address (street, city, state, zip code)
Physician’s Telephone Number (include area code)
Diagnosis of Condition Causing Disability (Indicate degree of severity)
n n
n n
n n
n n
Is this disability permanent?
Yes
No
If No, will the disability last at least twelve months?
Yes
No
Current medications or treatment for this disability
Treatment or services that may be needed in the near future for this disability
Date child was last treated
Is child incapable of self-support by reason of a mental/physical
If Yes, date child became incapable of
n n
n n
(month, day, year)
disability?
Yes
No
self-support (month, day, year)
n n
n n
Is child confined in an institution?
Yes
No
If Yes, Name of Institution
Signature of
Please Print
Date
Physician:
Name:
/
/
INSTRUCTIONS
1. The form needs to be completed in its entirety (front and back pages).
2. Please see eligibility requirements for a disabled child at the top of page 1.
3. Send this form to:
Highmark Blue Cross Blue Shield Delaware
Underwriting 1-8-10
PO Box 1991
Wilmington, DE 18999-1991
Or fax the form to: 1-877-731-4883
FOR HIGHMARK DE USE ONLY
Visit our website: www.highmarkbcbsde.com
Highmark Blue Cross Blue Shield Delaware is an independent licensee of the Blue Cross and Blue Shield Association
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