Anthem Enrollment Application
Social Security no.* (required)
Section D: Coverage information — All fields required. Attach a separate sheet if necessary. Dependent information must be completed for all additional dependents (if any) to be covered under this coverage. An eligible dependent may be your spouse or domestic partner, your children, or your spouse’s or domestic partner’s children (to the end of the calendar month in which they turn age 26 unless they qualify as a disabled person). List all dependents beginning with the eldest. Spouse/Domestic Partner last name First name M.I. Social Security no.* (required)
Disabled Yes
Birthdate (MMDDYYYY)
Relationship to applicant Spouse
Sex
Male
Female
No
Domestic Partner
PCP name
PCP ID no.
Existing patient? Yes No
Dependent last name
First name
M.I.
Social Security no.* (required)
Sex
Disabled Yes
Birthdate (MMDDYYYY)
Relationship to applicant Biological child of applicant/spouse/domestic partner Other If other, what is relationship? _______________________________
Male
Female
No
PCP name
PCP ID no.
Existing patient? Yes No
Does this dependent have a different address? No If yes, please enter: ____________________________________________________________________________________________ Dependent last name First name M.I. Social Security no.* (required) Yes
Disabled Yes
Birthdate (MMDDYYYY)
Relationship to applicant Biological child of applicant/spouse/domestic partner Other If other, what is relationship? _______________________________
Sex
Male
Female
No
PCP name
PCP ID no.
Existing patient? Yes No
Does this dependent have a different address? No If yes, please enter: ____________________________________________________________________________________________ Dependent last name First name M.I. Social Security no.* (required) Yes
Disabled Yes
Birthdate (MMDDYYYY)
Relationship to applicant Biological child of applicant/spouse/domestic partner Other If other, what is relationship? _______________________________
Sex
Male
Female
No
PCP name
PCP ID no.
Existing patient? Yes No
Does this dependent have a different address? No If yes, please enter: ____________________________________________________________________________________________ Yes
13 STERLING ESTATES 2023 BENEFITS GUIDE
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