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Add Dependent Instructions
Please refer to the sample Medical Insurance Enrollment form.
- Action box--check the box for Add Dependent.
- Carrier box--check the Enroll box for Health Net or Blue Cross.
- Personal Information--First and Last Name are necessary. You need enter the address only if there is an address change.
- Social Security Number--Required for the main enrollee! Our database, as well as those of all our insurance carriers are keyed on the SSN.
- Department, Title, Start Date Information--Not necessary on an Add Dependent form.
- Dependent Information:
Print names of dependents to be added.
Print birth dates. The insurance carriers use the date of birth as an identifier for dependents, especially if they have not yet received the SSN for the dependent.
Print social security number.
Print gender. The carriers need Male or Female listed for each enrollee.
Print the relationship to the enrollee (husband, wife, partner, son, or daughter). - Signature of the main enrollee--Required. The main enrollee must sign and date an Add Dependent form or it will not be processed. Eligibility: there must always be documentation of what has created a Period of Initial Eligibility (PIE) for the dependent(s). For a newborn give the date of birth. If just married, give the date of marriage. If the dependent(s) have just arrived in this country, please send a copy of the entry visa for each individual being enrolled. The entry date stamp must be clearly shown on the copies. The PIE is 30 days from the date of marriage, date of birth, arrival in the US, etc.
- FUND/DPA Information for Postdoctoral Scholars--Not necessary on an Add Dependent form. Additional charges for dependents will be charged to the main enrollee�s Fund/DPA. If changes to the Fund/DPA are needed, indicate them or use an RAD form (Recharge Authorization from Departments).
- Chair, Program Director, MSO or P.I. Signature--Required on an Add Dependent form.
- Contact Person Name--Since your responsibility as Departmental Contact person is to keep track of all insurance enrollments, charges, changes, and terminations for your enrollees, we will not process any insurance action that you do not know about. Please sign the form.
- Distribution--Send the original, signed form to Human Resources Office. Retain a copy for the Department file and another copy for the Resident or Fellow.