Application for Continued Health Plan
Eligibility for Over Age Dependents
The Ohio State University Office of Human Resources
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Application for Continued Health Plan Eligibility
For dependents over the age of 23 who are incapable of self-sustaining employment by reason a physical or mental disability or
impairment and are primarily dependent on the employee for support.
To be completed by employee
Dependent Child’s Name (Last, First, Middle Initial)_____________________________________________________________________
Male Female Dependent’s birth date _______________________ Relationship to Employee ________________________
Employee Name ________________________________________OSU Employee ID # _____________________________________
NGS Member ID # (from OSU medical card) _______________________________________________________________________
City ________________________________State ________________________________Zip _________________________________
Dependent’s Marital Status
Single Married Other ___________________________________ Date of Dependent’s Disability ____________________
Is this dependent residing in your household?
If no, explain: ________________________________________________________________________________
Do you provide more than half of this dependent’s support?
If yes, % of total: _____________________________________________________________________________
Please return this application with the enclosed physician statement completed by the dependent’s attending physician. If your
dependent has received an Award of Social Security Disability Benefits, you may submit it with your completed questionnaire
instead of the physician statement.
Verification of dependent eligibility will be requested periodically.
I understand that, as an Ohio State h