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Student Status Verification
* Indicates required information
Subscriber (Employee) Name
*
Dependent Name
*
Dependent ID Number
*
Relationship to Subscriber
*
Select the situation that best describes your dependent.
*
1. Dependent is totally or permanently disabled and incapable of self support.
(Please mail documentation from a primary care provider (PCP) or specialist(s) to
Community Health Plan, 137 N. Belt Highway, St. Joseph, MO 64506.)
2. Dependent is not currently enrolled nor intending to enroll as a full-time
student.
(Answer #6 below)
3. Dependent is currently in high school.
(Answer #6 below)
4. Dependent will be enrolled as a full-time student.
(Answer #7, #8 and #9
below
5. Dependent is currently enrolled as a full-time student.
(Answer #6 and #9
below)
6. Dependent's anticipated graduation date (mm/dd/yyyy)?.
7. If you selected Option 4, when will your dependent be enrolled in school (mm/dd/yyyy)?
8. If you selected Option 4, what is the anticipated graduation date (mm/dd/yyyy)?
9. If you selected Options 4 or 5, please provide the Name and City, State of the Educational Institute:
I would like to request information about your individual health coverage for my dependent.
Full Name
Address 1
Address 2
City/State/Zip
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