Page 1 of 3
29310279 • 8-19
Unique Member Identiﬁer
Dependent’s Name Social Security Number
Medicare ID Card Number
Hospital Part A Eective Date Medical Part B Eective Date Prescription Drug Part D Eective Date
Subscriber’s Statement – To Be Completed By Subscriber
1. Does dependent reside at the home of the subscriber?
No – If no, why? (ie. divorce decree, group home, residential facility)
Address of dependent:
Address City State Zip Code
2. Is the dependent claimed on the subscriber’s federal tax income return?
3. Is the dependent unmarried?
4. Is the dependent capable of ANY employment?
If yes, is the dependent employed?
Number of hours per week:
Method of transportation to and from job (drives car, uses public transportation, uses special van
(ie. “Handiwheels”, etc.):
5. Does dependent have a diagnosis of intellectual disability?
6. Does dependent have a diagnosis of physical disability?
7. Does dependent have a diagnosis of any seizure disorder?
Yes – If yes, when was the last seizure?
Medication, dose and frequency:
Number of seizures per day:
8. Does dependent attend school?
Yes – If yes, Where?
What grade level:
Mainstream (in non special education class) experience:
Application For Intellectual Disability
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Noridian Mutual Insurance Company