University of California
Declaration of disability for overage dependent child
Enrolled dependent children who would normally lose their eligibility under this plan solely because of age,
but who are disabled by reason of a physically or mentally disabling injury, illness, or condition, may have
their eligibility extended by written application within 31 days of the date the dependent child reaches
the age eligibility wo
uld otherwise cease.* To qualify for this extension, the disabled dependent child must
be incapable of self-sustaining employment and be chiefly dependent on the subscriber for support
and maintenance.
Please send your completed form by mail to: Blue Shield of California, Attn: Over Age Dependent Review – SGUW,
3021 Reynolds Ranch Parkway, Lodi, CA 95240; or fax it to: (916) 350-7170.
Subscriber information
First name: Last name: MI:
Member ID #:
Group # (check one box):
UC Care 976301
Core 976302
Medicare PPO without Rx 976303
Medicare PPO with Rx 976304
High Option Supplement 976305
Health Savings Plan 976350
Dependent child information
First name: Last name: MI:
Date of birth:
Physician information
Name of physician Contact phone number ( )
Diagnosis:
Prognosis:
Estimated date of ability for self-sustaining employment:
Physician statement
I, the undersigned physician, certify that the dependent listed above is incapable of
self-sustaining employment because of diagnosis above.
Physician's signature Date
Parent or guardian statement
I, the undersigned parent or guardian, certify that my dependent listed above is an
unmarried child (including any stepchild, legally adopted child, or foster child), is chiefly
dependent on me for support and maintenance, and is incapable of self-sustaining
employment by reason of physical or mental disability.
Parent or guardian's signature Date
* If the parent or guardian and dependent have not been covered by a Blue Shield health plan prior to the age that dependent eligibility ceases, evidence of
current prior dependent coverage will be required. For these situations, the HIPAA certificate from the prior carrier will be r
equired.
Blue Shield of California is an independent member of the Blue Shield Association
C3674-UC-PPO-FF (2/14)
